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HEALTH SCIENCESUBW^ 



anuary/ 
■ebruary 1996 

Volume 57 
Jumber 1 



he Official 
ournal of the 
Jorth Carolina 
Medical Society 



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North Carolina 
Medical Journal 



For Doctors and their Patients 



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Tlie Growing Peril of Rabies 
in North Carolina 

Information for the Medical Practitioner 



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NORTH CAROLINA 
MEDICAL JOURNAL 

For Doctors and their Patients 



EDITOfl 

Francis A. Nedon, MD 

DEPUTY EDITOR 

Edward C. Halpenn. MD 

CONSULTING EDITOR 
Eugene A. Stead, Jr., MD 

ASSOCIATE EDITORS 

Eben Alexander, Jr., MD 

Winston -Salem 
William B. Blyihe. MD 

Chapel Hill 
F. Maxlon Mauney, Jr., MD 

Asheville 
James P. Weaver. MD 

Durham 

MANAGING EDITOR 

Jeanne C. Yohn 

Durham 
919/286-6410 
fax: 919/286-9219 

BUSINESS MANAGER 
Donald R. Wall 



SECTION EDITORS 

Eugene W, Linfors, MD 
Daniel J. Sexton, MD 

EDITORIAL BOARD 
CHAIR 

Margaret N. Haiker.MD 
Morehead City 

MEMBERS 
Jack Hughes, MD 

Durham 
Patrick D. Kenan. MD 

Durham 
Assad Meymandi, MD 

Raleighi 
William G. Porter. MD 

Charlotte 
MaryJ. Raab, MD 

Greenville 
C. Stewart Rogers, MD 

Grecnboro 
J. Dale Simmons, MD 

Raleigh 
Thomas G. Stovall, MD 

Winston-Salem 



January/February 1996, Volume 57, Number 1 

Published bimonthly as the official organ of the 

North Carolina Medical Society (ISSN 0029-2559) 

The Society is not to be considered as endorsing the views and opinions advanced by authors of 
papers delivered at the Annual Meeting or published in the official publication of the Society. — 
Constitution andBylaws of the North Carolina Medical Society, Chap. IV, Section 3, pg. 4. 



NORTH CAROLINA MEDICAL JOURNAL 

Box 3910, Duke University Medical Center, Durham, NC 27710, (phone: 9I9/2W-6410, 
fax: 919/2*6-9219), is owned and published by the North Carolina Medical Society under the 
direction of its Editoria] Board. Copyright© 1996 North Carolina Medical Society. Address 
manuscripts and communications regarding editorial matters, subscription rates, etc., lo the 
Managing Editor at the Durham address listed above. (Use the following address for ovemight 
andexprcss mail only: 2200 W. Main St., Suite B-210. Room 12, Durham, NC 27705.) listed in 
Index Medicus. All advertisements arc accepted subject to the approval of the Editorial Board of 
the North Carolina Medical Journal. The appearance of an advertisement in this publication 
does not constitute any endorsement of the subject or claims of the advertisement 

Advertising representative: 

Don French, 318 Tweed Circle. Box 2093. Gary. NC 2751 1. 919/467-8515, fax: 919/467-8071 

Printing: The Ovid BeU Picss. Inc.. 1201-05 Bluff St., Fulton. MO 65251, 800/835-8919 

Annual subscription (6 /ourna/ Issues): $20 (plus 6% sales tax = $21.20). Single copies: $3.50 
regular issues. $5 special issues. Roster $55 (plus 6% sales tax). Second-class postage paid at 
Raleigh NC 27601, and at additional mailing offices. 

POSTMASTER: SEND ADDRESS CHANGES TO THE NORTH CAROLINA 
MEDICAL SOCIETY, 222 N. PERSON ST^ P.O. Box 27167, RALEIGH, NC 27^11-7167. 




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1<CMJ / January 1996, Volume 57 Number 1 



orth Carolina Medical Journal 

FOR DOCTORS AND THEIR PATIENTS 

January/February 1996, Volume 57, Number 1 

Cover: Epidemiologist and veterinarian Dr. Lee Hunter and Stale Health Director Dr. Ronald Levine discuss the spread of wildlife rabies 
and report on two different strains of raccoon rabies that are rapidly spreading across eastern North Carolina. See articles on pages 8 and 
14. Photo by Jay Levine, DVM, MPH, College of Veterinary Medicine, North CaroUna State University, Raleigh. Used with permission. 



THE STATE OF OUR HEALTH 

8 Conjoint Report: To the North Carolina Medical Society and the North Carolina Commission for Health Services 
Ronald H. Levine. MD, MPH 

PUBLIC HEALTH 

14 Rabies Epidemics in North Carolina, 1995: Information for the Medical Practitioner 
Lee Hunter, DVM. MPH 

1 8 Encouraging Physical Fitness as an Immunization Against Chronic Disease 
Edward B.Yellig.MD 



11 



A PIECE OF A NORTH CAROLINA DOCTOR'S MIND 

Death Worship, Carolina Style Gregory J. Davis, MD 



lA 



FICTION BY PHYSICIANS 

Deliverance 



Richard B. Weinberg, MD 



HEALTH IN THE WORKPLACE 

3 1 Violence and Work Injury: A Revealing Look at Turbulent Times 
Anthony H.Wheeler. MD. and Robert D.Ruth, PhD 



36 Valuing Workers Lessens Back Injury-Related Disability 



Anthony H. Wheeler, MD 



MODERN MEDICINE 

42 Sclerotherapy of Telangiectases Using Sodium Tetradecyl Sulfate (Sotradecol) 

Catherine Hren, MD, Carlos Garcia. MD. and Robert E. Clark. MD, PhD 



47 



SCREENING FOR DISEASE 

Prostate Cancer Screening Update: Should New Developments Change Our Practice? 



J^ey G. Wong, MD 



HEALTH WATCH 

27 Attention Deficit Hyperactivity Disorder 



Barbara Hollandsworth Smith, MD 



BULLETIN BOARD 

4 Letters to the Editor 
12 Instructions to Authors 
38 Subscription Form 
40 CME Calendar 



51 New Members 

55 Classified Advertisements 

56 Aphorisms of the Month 
56 Index to Advertisers 



NCMJ / January 1996, Volume 57 Number I 



Letters to the Editor 



^ 



A Family Affair 
To the Editor: 

Thank you so much for sending me copies of the August 
and November (Medical History) issues of the North Carolina 
Medical Journal. 

Since my husband Robert began editing ihc Journal more 
than 30 years ago, our whole family has had an interest in it. Our 
family trips and foibles turned up in editorials, and previews of 
coming attractions were often topics of dinner conversation. 
Our daughter Claudia was pleased that she was given an 
opportunity to contribute to the publication her father worked 
hard to nurture. 

Robert' s grandchildren will each get a copy of the Novem- 
ber issue. Your tribute to him means a lot to all of us, and I thank 
you again. 

Hellen B. Prichard 

2751 Club Park Road 

Winston-Salem, NC 27104 

Haywoods' History 
To the Editor: 

I want to thank the Journal and author Charles E. Williams 

for the article on my great-great grandfather. Dr. Edmund 

Burke Haywood, in the November issue on Medical History 

(NC Med J 1995;56:548-52). I knew some of the facts included 

in the article, but I also learned a few things of which I was not 

aware. I must admit that in reading the piece, I allowed myself 

to indulge in a bit of familial pride, not too great a sin I hope. 

Hubert B. Haywood, III, MD, FACP 

Raleigh Infectious Diseases Associates, PA 

2500 Blue Ridge Road, Suite 219 

Raleigh, NC 27607 



Disease in North Carolina 
To the Editor: 

I found the November issue of the North Carolina Medical 
Journal very interesting. In paticular, I was intrigued by Dr. 
Barry Kraus's article on the yellow fever epidemic in Wilmington 
(NC Med J 1995;56:580-2). 

As an appreciative reader, I thank Guest Editor Dr. Bill 
Blythe for the effort he put into this issue. 

Thomas M. Slubbs, MD 

Department of Obstetrics and Gynecology 

Carolinas Medical Center 

Charlotte, NC 28232-2861 



Credit Where It's Due 
To the Editor: 

I was very impressed by the special November issue of the 
North Carolina Medical Journal that Dr. Bill Blythe and the 
late Dr. Bob Prichard put together. It was a pleasure lo read, and 
I thank you for it. 

Eben Alexander, Jr., MD 

Professor Emeritus 

Department of Neurosurgery 

Bowman Gray School of Medicine 

Medical Center Boulevard 

Winston-Salem, NC 27157-1029 

Managed Care or Managed Costs? 
To the Editor- 
Recently, the wife of one of my patients asked that I visit 
her bedridden, multiproblem, non-ambulatory husband in their 
home. I had made previous visits there to evaluate his condition, 
adjust his medicines, and deal with the dilemma of providing 
sufficient home health care as the various providers struggled 
with the various sources of payment. 

On arriving at the home, it was clear that the patient was 
stable but his elderly wife was agitated. She had been told that 
she needed a letter stating the reasons why her husband needed 
colostomy bags. I responded by stating that my patient needed 
them because he had a colostomy. I went on to write that if this 
could not be understood, I would be glad to elaborate. (I neither 
offered to send the president of the organization a used bag, nor 
certify that the bags were not being used to freeze vegetables.) 
I wonder about "denials," "documentation," "letters of 
justification," and "MD certification." Are they all delaying 
tactics? Do they actually save money? I would like to hear 
similar stories from Journal readers. 

James A. Bryan, II, MD 

Professor, UNC School of Medicine 

^ Divisionof General Medicine and 

Clinical Epidemiology 

CB# 7110, 5039 Old Clinic Bldg. 

Chapel Hill, NC 27599-7110 



A Way of Thinking About Dr. Stead 
From the Editor: 

The following anecdotes are excerpts of letters sent to the 
Editor about A Way of Thinking, A Primer on the Art of Being 
a Doctor, a collection of essays by former Journal Editor Dr. 



NCMS/ January 1996, Volume 57 Number 1 



Eugene Stead, which was reviewed in the December "Carolina 
Physicians' Booksheir (NC Med J 1995;56:635). We publish 
them here with the authors' permission. 

To the Editor: 

I enjoyed reading the new compilation of Dr. Eugene 
Stead's essays, /4 Way of Thinking, A Primer on the Artof Being 
a Doctor. Dr. Stead is a very thought-provoking individual 
whose thoughts, whenever they were spoken or written, are 
quite pertinent today. 

I do not believe that the characteristics of great physicians 
such as Osier and Stead are their research contributions, bril- 
liant diagnoses, or "teachable moments." Rather, it is their 
behavior toward their fellow humans that makes them special. 
I suspect that Dr. Stead's caring for patients, residents, faculty, 
and colleagues, whether gruff or kind in manner, sets him apart 
from his predecessors or his successors. 

Michael J. McFarlane, MD 

Assistant Professor of Medicine 

Case Western Reserve University 

at MetnoHealth Medical Center 

Cleveland, OH 44109-1998 



To the Editor: 

I enjoyed reading the book of Dr. Stead's essays. I'm find- 
ing that the older I get the more deeply I appreciate his insights 

and wisdom. r> . i a x^ i^ x^r^ 

Patnck A. McKee, MD 

George Lynn Cross Professor of Medicine 

Scientific Director 

William K. Warren Medical Research Institute 

University of Oklahoma Health Sciences Center 

Oklahoma City, OK 73104 

To the Editor: 

I read a good part of A Way of Thinking .APrimerontheArt 
of Being a Doctor, including the chapter on Jack Myers, on my 
way home from a recent trip to Durham. I think a couple of the 
chapters may be useful as readings for the professionalism 
module of our Medicine in Contemporary Society course. 

Jack Coulehan, MD 

Division of Medicine in Society 

Department of Preventive Medicine 

Stony Brook Health Sciences Center 

State University of New York at Stony Brook 

Stony Brook, NY 11794-8036 



A Modern Sisyphus 

J. Trig Brown, MD, MPH, Chief, Internal Medicine, The Carolina Permanente Medical Group, Durham-Chapel Hill Service 
Area, and Clinical Associate Professor, UNC Department of Medicine, Chapel Hill 



It's 4:30 in the afternoon. My energy gauge reads "EMPTY." 
I pull the chart from the rack and notice that the patient had 
a 3:30 appointment. Not only am I one hour late, I feel as if 
the last five patients have all had 3:30 appointments. 

Am I locked in a fime warp? Is this my Purgatory? 
Worse still, my Hell? On days like today I feel that, had there 
been primary care cUnics in early Greece, the general inter- 
nist, not Sisyphus, would have been the icon of perpetual 
frustration. 

As I enter the room I don the mask of the cool, calm, and 
collected professional. I sit near my patient and resist the 
urge to fire off a salvo of closed-end, specific questions. An 
open-ended question brings forth a tidal wave of symptoms. 
It spills onto the floor and quickly rises to my knees. This 
patient clearly missed the lecture where we were told that 
patients rarely speak longer than two minutes if uninter- 
rupted. 

Many minutes and several interruptions later I finish the 
history and begin to examine the patient A good examina- 
tion should seem as smooth and fluid as a waltz between me 
and my patient There is nothing waltz-like today; a knock on 
the door, a page to the emergency room, a phone call from 
a consultant repeatedly cut in on me and my dance partner. 



History and examination over, I look to the labs. My 
frustration level goes even higher. Last week's results are 
not in the chart. Earlier today I was told that our computer is 
not working. I will be unable to retrieve any lab results. 

Despite all the inefficiencies, I glance at my watch to see 
that I'm really not too much farther behind. That small 
comforting ray of hope is quickly extinguished. The patient 
tells me that the pharmacy will need refills written for all of 
his medications — all 12 of them! "And, Doc, while you've 
got your pen out can you update my referrals to see the 
ophthalmologist, podiatrist orthopedist,...?" 

My task finally seems done. I have listened, touched, 
refilled, and referred. My hand is on the doorknob when our 
eyes meet again. "Doc, I don't know if this is important but 
I told my wife I'd ask.... Do you think there's anything 
serious with this crushing chest pain I get when I carry out 
the garbage?" We resume our dance for several more sets 
until the belated, but real, agenda is completed. 

As if to convince myself that this encounter is really 
finished, I watch this patient walk the entire length of the 
corridor. Out the exit I turn and pull the next chart off the 
rack. Another 3:30 appointment I place my shoulder to the 
boulder and slowly enter the room. □ 



NCMJ / January 1996, Volume 57 Number 1 



Guidelines for Letters: Letters must be typed and double-spaced. Letters are subject to editing and abridgment and should 
be no longer than 500 words. We will consider longer letters as editorials for possible publication elsewhere in the Journal. 
For longer letters, send a 3 1/2-inch computer diskette with the text written in MS DOS- or Macintosh-compatible format. We 
customarily send letters that address specific points in articles to the original authors for response. Send letters to: North 
Carolina Medical Journal, Box 3910, Duke University Medical Center, Durham, NC 27710, fax: 919/286-9219. 



/T 



"^ 



Attention Journal readers: 

Starting with this issue, the North Carolina Medical Journal begins its new schedule of 
publishing every other month. (Fordetails read Dr. Neelon's editorial, NC Med J 1 995;56:600- 
1 .) Subsequent issues will be published in March, May, July, September, and November. The 
North Carolina Medical Society's Roster w\\\ be published as a supplement in August. The 
Bulletin will continue to be mailed monthly to Society members. 

Send all submissions and comments and suggestions for the Journal \o Box 3910, Duke 
University Medical Center, Durham, NC 27710, 919/286-6410, fax: 919/286-9219. 



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THE STATE OF OUR HEALTH 

Conjoint Report 

To the North Carolina Medical Society and 

the North Carolina Commission for Health Services 

Ronald H. Levine, MD, MPH 



Editor's note:Th\s report is an adaptation of State Health Director Dr. Levine's address to the Medical Society at its Annual 
Meeting in Pinehurst November 10, 1995. 



It is a privilege for me once again to highlight several current 
public health issues and challenges. And to dwell at somewhat 
greater length on special opportunities for us all to contribute to 
the better health of our society. 

I begin at the beginning of the life cycle (an unavoidable 
choice, I suppose, for a pediatrician). I am pleased to confirm 
that North Carolina's infant mortality rate decUned this past 
year to 10 deaths per 1 ,000 live births— the second lowest rate 
in our history and a decline of more than 20% since 1988, when 
we achieved the dubious distinction of having the highest 
statewide infant mortality rate in the nation. 

The medical community has played an important role in 
our progress. Widespread use of surfactant and corticosteroids 
has made the difference between life and death for many 
extremely premature neonates. Appropriate transfer of women 
in preterm labor to tertiary care centers has increased the 
number of very low birthweight babies bom in level III hospi- 
tals (where birthweight-specific mortality data tell us they 
should be bom). The success of efforts to provide accessible 
prenatal care and to promote healthy behaviors by pregnant 
women has led to an increased percentage of women who 
initiate care in the first trimester and to a decreased percentage 
of women who smoke during pregnancy. 



positive difference. Neural tube defects have devastating con- 
sequences, and each year in North Carolina, one child in every 
1 ,000 is bom with one — twice the rate of most other states. We 
can prevent most of these defects merely by ensuring sufficient 
intake of folate by women before and during pregnancy. Be- 
cause the spinal cord closes on the 27th or 28th day after 
conception, women must have adequate levels of folate even 
before they know that they are pregnant Every woman of 
childbearing age should receive folate daily regardless of 
whether she is planning to become pregnant. Remember, fully 
half of all pregnancies are unplanned. 

Many foods contain folate, but some women need supple- 
ments to ensure sufficient intake. Unfortunately, most women 
do not realize how important it is to have adequate folate levels. 
A state task force has been convened to educate both health care 
providers and the public about the critical role of folate in 
preventing birth defects. Health care providers will be encour- 
aged to discuss this with patients who are liable to become 
pregnant and to counsel them about the need to eat foods high 
in folate and take supplementary folate if necessary. This 
exciting initiative has a major positive payoff for mothers, 
children, and the community. We look forward to working with 
you on it 



Preventing Neural Tube Defects 

The prevention of neural tube defects such as spina bifida is 
another area in which, together, we clearly could make a 



Childhood Immunizations 

There is good news to report in another child-health area: We 
are getting our children appropriately immunized. In January 



Dr. Levine is State Health Director, NC Dept. of Environment, Health, and Natural Resources, P.O. Box 27687, Raleigh 27611. 



^CMJ/ January 1996, Volume 57 Number 1 



1994, the University of North Carolina School of Pubhc Health 
reported a significant increase in immunization rates for six- 
month-old infants. In January 19%, the school will report the 
rates of immunization for 19-month-old children. The forth- 
coming report should demonsffate the effect of North Carolina' s 
universal vaccine distribution and immunization outreach cam- 
paigns. Meanwhile, the Centers for Disease Control and Pre- 
vention has ranked North Carolina's age-appropriate immuni- 
zation rates for 19- to 35-month-old children fourth best in the 
nation: 84% of oiu" children had been appropriately immunized 
with four doses of DPT, three OPV, and one MMR. We know 
that more than 90% of the public and private health care 
providers who administer vaccine to children participate in the 
state's universal childhood vaccine program; we continue to 
work towaid 100% participation. 



"...the CDC has ranked 

North Carolina's age-appropriate 

immunization rates for 19- to 

35-month-olcl children 

fourth best in the nation. 



rabies now stretching from Florida to Maine. 

Our state laboratory has confirmed the presence of rabies 
in 45 of North Carolina's 100 counties and the number of cases 
has more than doubled each year since 1990. Wild animals 
account for the vast majority of confirmed cases, but rabies has 
now been seen in cats, dogs, horses, and cattle, which greatly 
increases the potential for human exposure. 

A special effort is being made to provide rabies education 
for medical professionals through our Area Health Education 
Centers. Please be assured that professional consultation on 
possible exposures and how to manage them is available. 
During normal working hours, physicians may call the Division 
of Epidemiology (Occupational and Environmental Epidemi- 
ology) at 919/733-3410. During evening hours, weekends, and 
holidays, physicians may contact a beeper-voice mailbox at 
919/733-3419. 

A free booklet written for medical professionals. Manage- 
ment of Animal Bites, is available from the Division of Epide- 
miology (see Appendix). It provides dosage and schedule 
regimens for pre-exposure and post-exposure rabies vaccina- 
tion. In addition, the booklet discusses how to determine when 
vacination is appropriate, potential sequelae, and contraindica- 
tions of vaccination, and names and telephone numbers of 
Division personnel who can help. 



Screening Pregnant Women for HIV Preventive Services for the Elderly 



A serious and continuing challenge to healthy mothers and 
babies is, of course, the Human Immunodeficiency Virus 
(HIV). In July 1995, the US Public Health Service recom- 
mended routine, voluntary HIV testing and counseling for all 
pregnant women because studies (carried out in great part at 
North Carolina medical centers) showed that the treatment of 
infected women with azidothymidine early in pregnancy de- 
creased mother-to-baby transmission of HIV from 26% to only 
8%. Our health services commission now requires physicians 
who treat pregnant women to offer HIV counseling and testing 
services to all pregnant women under their care. Oiu' depart- 
ment has been meeting with providers across the state to 
develop a plan for implementing this new regulation and to 
identify the additional support that our practitioners will need. 
We are developing an HIV counseling and testing video for use 
in prenatal clinics and practices across the state to assist you in 
this important initiative. 



Now, let me discuss a superb opportunity for us to work 
together to make a difference at the far end of the life cycle. 
What images do we conjiu^e up when we hear "prevention" and 
"public health?" A small child getting immunized or a pregnant 
woman obtaining quality prenatal care? I want to suggest a few 
more images of "prevention" that ought to come to mind: a 



"...our culture needs to recognize 

that our older citizens. . .contribute to 

society long after their 'working' years 

are over;... maintaining a high quality 

of life is a necessary part of a long 
'active life expectancy.'" 



The Growing Peril of Rabies 

Another frightening communicable disease menaces our chil- 
dren, indeed our citizens of all ages. Wildlife rabies has pen- 
etrated North Carolina. (See article on page 14.) There is rabies 
in skunks in the northwestern part of the state, and two different 
strains of raccoon rabies are rapidly spreading across eastern 
North Carolina. In effect, there is a massive epidemic of wildlife 



nutritionist advising a group at a senior center on how to 
increase dietary fiber; a physician inspecting the feet of a 63- 
year old diabetic man or discussing with a 78-year-old woman 
how to manage her six prescription medicines. Or how about 
this one: the manager of a senior housing complex skid- 
proofing the stairs of a resident's apartment. You see the 
pattern. Our growing elderly population is our largest user of 
health care services, but it is long overdue for targeted preven- 
tion both by the community and private practitioners. A quick 



NCM J / January 1996, Volume 57 Number 1 



look at the numbers confirms the need to beef up our efforts at 
preventing disease and disability in this age group: In 1990, 
North Carolina was home to 800,000 persons age 65 and older; 
by 2005 we wiU add another 300,000. 

What can we do to prevent, forestall, or reduce the need for 
acute and chronic treatment of disease among the elderly? It is 
a challenge to get effective heath promotion messages and 
services across to the elderly. Many are "set" in their ways; 
some are physically or socially isolated and don't have access 
to information and networks that can help. We need creative 
clinical, community, and home-based approaches. And — just 
as importantly — our culture needs to recognize that our older 
citizens represent a growing resource; that they contribute to 
society long after their "working" years are over; that maintain- 
ing a high quality of life is a necessary and achievable part of a 
long "active life expectancy." Not just "life expectancy" but 
"active life expectancy." 

Let me give you some examples of how we can achieve this 
goal in North Carolina. Patients come to individual practitio- 
ners with problems that need fixing. During those visits you can 
advocate health promotion through a quick assessment of needs 
followed by counseling or re- 
ferral to a program or service 
that can help. Some questions 
to help in your assessment in- 
clude: 



1 . How is your dietl Even pa- 
tients not on therapeutic di- 
ets still need specific nutri- 
tion education materials and 

services targeted to the 

needs of older adults. 

2. Do you smoke? Brief, regular advice about quitting is a 
powerful tool, especially if the patient realizes that there are 
health benefits to be had from quitting even at an older age. 

3. Have you had your influenza or pneumococcus vaccine? 
Does the patient know that Medicare pays for flu shots 
without a deductible or coinsurance payment? 

4. When was your last Pap smear or breast screening exam 
including a mammogram? More than half the women in 
North Carolina over 50 years old do not regularly get these 
proven preventive services — despite the fact that many 
third-party payers cover the costs, and pubhcly funded 
screening is available statewide for low-income women. 

5. Let me look at all your medicines. Remember to check for 
duplicate prescriptions and for those that are contraindi- 
cated. Simple check-off sheets containing these and other 
questions can give you an idea of the status of your older 
patients' levels of risk and provide clues about appropriate 
interventions. Getting the information also involves elderly 
patients in managing their own health. Encouraging pa- 
tients' personal responsibility for their health and empower- 
ing them by providing information and skills are key steps 
toward health improvement. 



"Encouraging patients' personal 

responsibility for their health and 

empowering them by providing 

information and skills are key steps 

toward health improvement." 



Help is Available 

We now have available for clinicians a useful tool for imple- 
menting health promotion within a busy practice. The US 
Department of Health and Human Services* Putting Prevention 
Into Practice kit provides materials with which both clinician 
and patient can enhance and document prevention activities in 
the practice setting. A central component of the kit, theClinician' s 
Handbook of Preventive Services, is a compendium of current 
recommendations on prevention for both children and adults 
(see Appendix, next page). 

You can facilitate community-based prevention and health 
promotion by referring elderly patients to appropriate pro- 
grams: congregate nutrition sites; cancer and hypertension 
screening services sponsored by local health departments; 
glaucomaand deafness screening; exercise programs in YMCAs; 
support groups for persons with diabetes, cancer, heart disease, 
mental illness, etc. North Carolina has developed the Senior 
Phone Directory to help with such referrals (see Appendix). 

Unfortunately, many of the prevention programs offered to 
seniors focus on only one or two risk factors, or seek to address 

only partof a health need. We 
need cross-cutting measures 
if we are to realize the full 
potential for prevention. Let's 
look at the problem of hip frac- 
tures to see how this can work. 
In the United States, there are 
more than 250,000 hip frac- 
tures every year, a number that 
is sure to rise with the increas- 
ing elderly population — un- 
less we take preventive steps. A comprehensive program in a 
community could include: 

• Home safety inspections, perhaps by a health department 
inspector. 

• Correction of hazardous conditions in the home, by 
installing railings and non-skid materials, or even by remov- 
ing a "slippery" rug. 

• Fitness programs, based either in the home or in commu- 
nity facilities and tailored to promote strength, flexibility, 
and balance in the elderly. 

• Nutrition programs to encourage diets that minimize bone 
loss and prevent osteoporosis. 

• Medication management to reduce the risk of orthostatic 
hypotension or syncope. 

We could probably implement such a program in the 
community at relatively low cost, especially if multiple organi- 
zations joined in partnership. The payoff would be tremendous: 
Preventing one hip fracture would save $40,000 in first-year 
treatment costs alone! In about one quarter of cases, we would 
also save the costs of long-term institutional care. And of 
course, we would save things difficult to measure — mobility, 
independence, self-reliance — ^all of which help reduce the bur- 
geoning overall health care costs of the elderly. 



10 



NCMJ / January 1996, Volume 57 Number 1 



We have taken some initial steps to establish a broad plan 
for this type of health promotion for our older adults. A group 
of about 40 of the state's experts in health and aging recently 
met in Chapel Hill to review the demographics and explore the 
health needs of the elderly, to develop a consensus on highest 
priority goals, and to develop strategies for reaching these 
goals. A written plan is anticipated next spring, and I would like 
to ask in advance for your assistance and participation in 
making its implementation a reality. To accomplish this to- 
gether on behalf of one of our most precious resources will once 
again demonstrate North Carolina's uniquely successful col- 
laboration between public health and the practitioners of clini- 
cal medicine. Q 



Appendix 

• To order the free booklet, Management of Animal 
Bites: contact Lee Hunter, DVM, MPH, Environ- 
mental Epidemiology Section, P.O. Box 27687, 
Raleigh, NC 27611-7687, 919/733-3410. 

• To order Putting Prevention Into Practice kit : send 
$57 for stock #017-001-00492-8 to Superinten- 
dent of Documents, P.O. Box 371954, Pittsburgh, 
PA 15250-7954. Kit includes the C//n;c/an'sHand- 
t)ook of Preventive Sen/ices (or order separately 
for$20, stock #01 7-001 -00496-1). Fax credit card 
orders to 202/512-2250. 

• To order the Senior Phone Directory: contact 
Betty Wiser, Director, Aging Program, Division of 
Health Promotion, P.O. Box 27687, Raleigh, NC 
2761 1-7687, 919/715-0122. The D/rectory is free; 
a new version is due out in February. 



r 



WRYmes 

by Mae Woods Bell 



=\ 



Update 

New Year's Resolutions are being adopted by 
Wry ones and shy ones and bold ones— 
As for me, I don't plan to join that crowd, 
I just recycle my unused old ones. 

Say "Aah" 

I've an appointment with my doctor, 

To be told, I have no doubt. 

What it is I'll have to live with. 

And what I'll have to learn to live without. 



From Bottlenecks Are at the Top, by Mae Woods Bell. Falls of 
the Tar Publications. Rocl<y Mount. Used witt> permission. 



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Instructions for Authors 



The North Carolina Medical Journal is a medium for 
communication with and by members of the medical com- 
munity of this state. The Journal publishes six times a year: 
in January, March, May, July, September, and November. 
The Journal will consider forpubhcation articles relat- 
ing to and illuminating medical science, practice, and his- 
tory; editorials and opinion pieces; letters; personal ac- 
counts; poetry and whimsical musings; and photographs and 
drawings. Papers that relate to the present, past, or future 
practice of the health professions in North Carolina are 
especially pertinent, but manuscripts reflecting other per- 
spectives or topics are welcomed. Prospective authors should 
feel free to discuss potential articles with the editors. 



Manuscript Preparation 

Prepare papers according to the "Uniform Requirements for 
Manuscripts Submitted to Biomedical Journals" (N Engl J 
Med 1991;324:424-8) with the following exceptions: 1) no 
abstract is needed; 2) no running title is needed; and 3) report 
measurements in metric units; use of the International Sys- 
tem of Units (SI) is optional. 

Submit a cover letter and either a 3 1/2-inch hard disk or 
5 1/4-inch floppy computer disk that contains the text written 
in MS DOS- or Macintosh-compatible format, and at least 
one hard copy of the text. Double space text with one-inch 
margins. Please do not "format" the text (e.g. no variations 
in type size, no bold face, no italics, no embedded endnotes). 

Submit illustrations, in duplicate, in the form of high- 
quality color 35mm slides or 5-by-7-inch or 8-by-lO-inch 
glossy photographs, or as black-and-white glossy prints (5- 
by-7-inch or 8-by-lO-inch). Label all illustrations with 
author's name, number them sequentially according to their 
position in the text, and indicate the orientation of the 
images, if necessary. Do not write directly on the backs of 
prints. This can damage them. If figures require printing in 
four-color process, the author may be asked to pay printing 
fees or a portion thereof. 

Type figure legends, double-spaced, on a separate sheet 
of paper. Tables should be typed, double-spaced, one to a 
single sheet of paper. All tables must have tides and consecu- 
tive Arabic numbers. Include tables, graphs, or charts on 
disk, if possible. 

Keep references to a minimum (preferably no more than 



15), retaining those that document important points. The 
"Uniform Requirements" cited above contain reference for- 
mat We customarily list the first three authors for "et al"- 
type references. Authors are responsible for the accuracy 
and pertinence of all citations. 

Avoid abbreviations entirely if possible; keep them to a 
minimum if not When used, completely define abbreviations 
at the first point of usage in the text. 



Manuscript Review and Editing 

A medically qualified editor reads all manuscripts and, in 
most instances, sends them out for further review by one or 
more other members of the North Carolina Medical Society. 
Authors' cover letters must include a line that states that 
their submitted manuscripts are not under considerationfor 
publication elsewhere. Decisions to pubUsh or not are made 
by the editors, advised by the peer reviewers. 

We encourage a relatively informal writing style since 
we believe this improves communication. Imagine yourself 
talking with your unseen audience — as long as this doesn't 
lead you to scientific or linguistic inaccuracy. Be brief, clear, 
simple, and precise. 

We edit accepted manuscripts for clarity, style, and 
conciseness. Except for letters, authors receive a copy of the 
edited manuscript for their review and approval before 
publication. Manuscripts not accepted will not be returned. 

Authors retain copyright to articles published in the 
North Carolina Medical Journal, but the North Carolina 
Medical Society copyrights the contents of each entire issue. 
Requests for permission to reprint all or any part of a 
published article must be submitted in writing to the address 
below and negotiated with the author and editor joinUy. 
Reprinted material must carry a credit line identifying that it 
appeared in the North Carolina Medical Journal. 



Submissions 

Address manuscripts and all other correspondence to: 
Editor, North Carolina Medicaljournal 
Box 3910, DUMC, Durham, NC 27710 
Telephone 9191286-6410 
Fax 919/286-9219 



12 



NCMJ / January 1996, Volume 57 Number 1 



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PUBLIC HEALTH 



Rabies Epidemics in 
Nortii Carolina, 1995 

Information for the Medical Practitioner 



Lee Hunter, DVM, MPH 



Rabies — long absent as a major health threat to the land-based 
animals of North Carolina — has now entered the state in three 
separate epidemics. As these epidemics spread from their entry 
points, the number of cases of rabies diagnosed by the State 
Laboratory of Public Health has increased dramatically, nearly 
doubling each year since 1990. 

The relative absence of rabies among land-based animals 
(that is, mammals other than bats) in North Carolina has made 
many people complacent. We have forgotten the lessons learned 
during the major rabies epidemic of the 1 950s. As a result, chil- 
dren are allowed to approach unknown animals, even animals 
that appear to be ill, and people bitten by animals do not always 
seek medical assistance. Many dogs and cats are not vaccinated 
against rabies. People have forgotten that, once signs and 
symptoms appear, human rabies is almost invariably fatal. 



The Rabies Epidemic of the 1950s 

The reason that the disease has been absent from land-based 
animals is the effectiveness of the public health programs 
launched to control rabies during the 1950s. In the mid-1950s, 
several hundred animals per year were diagnosed as rabid and 
there were some resulting human deaths. The main reservoir of 
rabies 40 years ago was the population of owned and stray dogs 
and cats. Efforts at the state and local level to control the spread 
of the disease within those populations efforts consisted of two 
main programs: 1) The North Carolina General Assembly made 
it mandatory that all dogs be vaccinated against rabies. The 
Commission for Health Services permitted the use only of 
animal rabies vaccines that could be proven effective. County- 
sponsored rabies vaccination clinics were made available state- 



Dr. Hunter is with the Medical Evaluation and Risk Assessment 
Branch, Occupational and Environmental Epidemiology Sec- 
tion, Division of Epidemiology, NC Department of Environment, 
Health, and Natural Resources, Raleigh 27611. 



wide to ensure that vaccination of dogs was affordable and 
accessible close to home. 2) Since rabies vaccination efforts did 
not reach the population of stray dogs, these animals were (and 
still are) unlikely to be vaccinated. They form a potential 
reservoir for the disease. In order to significantly interrupt the 
dog-to-dog cycle of rabies (and thereby reduce the total number 
of rabies cases), the carrying population (the population that 
allows the continuing transmission of disease in a population) 
must be reduced. Therefore, local animal control departments 
undertook a (successful) program to reduce the population of 
stray animals. 

These two efforts — mandatory mass vaccination with ef- 
fective vaccines and a reduction in the numbers of stray ani- 
mals—rapidly reduced the carrying population and brought the 
epidemic under control. For example, 174 animals in North 
Carolina were diagnosed as rabid during 1954,butby 1960only 
1 1 were. Controlling the disease in the pet population reduced 
the spillover of the disease into the wild animal population. 



Rabies Epidemics Today 

Now, the disease is threatening us once again. But not because 
of a failure of our established public health programs to deal 
with domestic animals. This time the threat comes from a new 
direction. The rabies epidemics in North Carolina predomi- 
nately affect the wild animal population. That makes the control 
of the disease much more difficult, if not impossible, given the 
tools we now possess. These epidemics are part of a larger 
regional problem affecting the Southeast, Mid-Atlantic, and 
Midwest United States. The reasons for the epidemic outbreaks 
are varied and complex. The epidemic in the northwestern part 
of the state affects mainly skunks, while that in the northeastern, 
southeastern, and south-central regions of the state affects 
primarily raccoons. The difference is due to the origins of the 
epidemics affecting each area. 

Figures 1-3, next page, show the counties affected and the 



14 



NCMJ / January 1996, Volume 57 Number I 



time sequence of the spread of the epidemics depict- 
ing 1990, 1993, and 1995, respectively. The con- 
tinuing and rapid spread of the disease across the 
state is noticeable. The maps do not depict counties 
that have experienced isolated cases of rabies not 
due to a natural extension of the epidemics. 

Three distinct epidemics of wild animal rabies 
have entered the state, and two have shown a strong 
tendency to spread quickly from their point of entry . 
The Southeastern Raccoon Rabies Epidemic origi- 
nated in Florida during the 1950s. The reasons for 
its movement are not completely clear, but we do 
know that the epidemic spread from Florida into 
Alabama, Georgia, and South Carolina. It moved 
into two separate regions (Figure 2) of southeastern 
and south-central North Carolina over a two-year 
period. Those two regions have now converged into 
a rough triangle including Gaston County (south- 
west), Harnett County (north), and Brunswick 
County (southeast) (Figure 3). Northern Georgia 
has experienced rabies in its raccoon population as 
part of the same epidemic, and extension from 
northern Georgia into western North Carolina is 
very possible. 

A second epidemic (the Mid- Atlantic Raccoon 
Epidemic) originated in Virginia as a result of 
human action: the translocation of wild raccoons 
from the Southeast into West Virginia and Virginia 
during the late 1970s. The infection has spread 
south into North Carolina, west into Ohio, and north 
and east into Pennsylvania, New Jersey, New York, 
and New England. In North Carolina, rabid rac- 
coons are now found in a roughly rectangular region 
from Granville County (northwest), northern Harnett 
County (southwest), Beaufort County (southeast), 
and Currituck County (northeast) (Figure 3). 

A third epidemic of rabies originated in skunks 
in Canada and spread through the midwestem states 
into Tennessee, southwestern Virginia, and north- 
western North Carolina. Thio Midwestem Skunk 
Epidemic no w affects Watauga and Alleghany coun- 
ties (Figure 3). 



Rabies Control Measures 





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1990 


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rabies epidemic: 1995 



As more counties experience epidemic rabies, the 
risks to citizens increase and the costs of trying to 
control the disease and treat people exposed to the 
virus increase. Financial aspects include medical costs for 
people or pets exposed to the disease; pre-exposure rabies 
vaccination of animal control officers, veterinarians and wild- 
life rehabilitators; vaccination of dogs and cats to prevent the 
disease; and county government funds for animal control. The 
state of New Jersey estimated that the cost of rabies control 



Figs 1-3 (top to bottom): North Carolina counties affected by rabies 
epidemics during 1990 (top), 1993 (middle), and 1995 (bottom). 



increased approximately 60% in two counties that experienced 
a rabies epidemic. Most of the increased costs were borne by the 
private sector, primaiily in the form of rabies vaccination for 
pets.' 

Controlling the spread of rabies in a wild animal population 
is a complex problem, and few have been successful. The 



NCMJ / January 1996, Volume 57 Number 1 15 



experiment of trapping and vaccinating wildlife across the base 
of a peninsula has been tried to stop the advance of the disease 
in a raccoon population. Despite a large investment of time and 
money, the rabies virus jumped this human-made barrier. 
Trapping and shooting wildlife to lower population levels have 
been tried and found ineffective (probably because such meth- 
ods would also have to prevent the in-migration of wildlife from 
surrounding areas). Damaging an area's ecology by decimation 
of wildlife may have serious and unintended consequences. 

A potential method of controlling the spread of the rabies 
virus is on the horizon. Wildlife can be given a bait containing 
an active, genetically engineered, live vaccinia virus that in- 
cludes genetic material coding for an external rabies protein. 
This method has been used in Europe to control rabies virus in 
foxes, and it holds much promise. Briefly, genetic material 
coding for an external protein of the rabies virus is inserted into 
the DNA of the vaccinia virus. This new virus, which is alive but 
altered from its original form, is placed into bait attractive to 
raccoons and distributed throughout the target area. The vaccinia 
virus enters the raccoon through its tonsils. The virus infects the 
host, producing a rabies protein in addition to more vaccinia 
virus. The host, in turn, produces antibodies against the vaccinia 
virus and the rabies protein. The genetically engineered vaccinia 
virus cannot produce rabies but can imm unize the host to rabies. 
Laboratory data suggest that horizontal and vertical transmis- 
sion may occur during the first few hours after immunization. 

Oral baiting has limitations. It is designed to protect a 
specific area such as a peninsula or camp. It is too expensive and 
labor intensive to be used to eradicate rabies in an entire stale or 
even most counties. No vaccine is 100% effective and this one 
is not expected to be any different. It is intended to immunize 
a population of animals and slow or stop the epidemic spread of 
rabies. It is a public health measure, not an individual veterinary 
medical procedure. 



Help for Health Professionals 



of Animal Bites, is available for free from the Division of 
Epidemiology (P.O. Box 27687, Raleigh, NC 27611-7687). 
This booklet gives dosage and schedule regimens for both pre- 
exposure and post-exposure rabies vaccination. In addition, it 
discusses how to determine when vaccination is appropriate, 
the fxjtential sequelae and conu^aindications of vaccination, and 
names and telephone numbers of Division staff who can help. 

The NC DEHNR maintains a stock of rabies vaccine and 
rabies-immune globulin for sale to physicians, pharmacies, 
hospitals, and health departments at cost on a non-exchange, 
non-return basis. Orders may be made through the Division of 
Epidemiology. Rabies vaccine and rabies-immune globulin 
may also be available through local and regional hospitals at 
comparable prices. Referral of patients to such hospitals may be 
indicated when treatment should be started immediately. 

There are many ways in which to mitigate the rabies risk in 
areas experiencing an epidemic. First, we must teach our 
children not to approach unknown animals, even those not 
showing signs of disease. Normal-appearing animals may have 
saliva capable of transmitting disease. Second, we must change 
certain habits that attract wild animals into our living space. 
Watching raccoons feeding in the backyard may be educational 
to our children and ourselves, but those raccoons pose a threat 
to our health and the health of our pets. Dog or cat food should 
not be left outside at night because it may attract wildlife. 
Garbage cans should have tightly fitting lids or have cords 
across the lids lo keep them securely fastened. Third — and one 
of the most important things we can do to protect our families — 
is to have our pets vaccinated against rabies. Vaccination is 
required by law, but many people neglect to do it until the 
epidemic is upon them. By then it may be too late. Eight rabid 
cats and two rabid dogs were identified in North Carolina in 
1993, the most pets in one yearsince 1959.Noneof these lOpets 
had been vaccinated. It has been my experience that, for every 
case of rabies in a pet, six people are forced to undergo 
antirabies vaccination. 



Determining whether people need post-exposure rabies vacci- 
nation is difficult because of the large number of variables 
involved: the species of animal, circumstances of the bite, the 
epidemiology of the disease. Help in making such decisions is 
available from the schools of medicine throughout the state, 
local health departments, and the North Carolina Department of 
Environment, Health, and Natural Resources (DEHNR), Divi- 
sion of Epidemiology. Assistance is available during normal 
working hours from the Division of Epidemiology (919/733- 
3410), and during evening hours, weekends, and holidays by 
calhng a beeper-voice mailbox (919/733-3419). 

A booklet written for medical professionals. Management 



A Last Word 

To summarize: the calm before the rabies storm has ended. 
Three epidemics of rabies have entered the state and spread 
from their point of entry. These events mean a large investment 
of time and money by state and local health departments to 
prevent human and pet animal cases of rabies. Since control of 
the disease in the wildlife population poses many challenges, 
the medical community will see increased demands on its time 
and expertise in hof)es of preventing human rabies. The expe- 
rience of our neighboring states shows that problem of rabies 
will affect all of our citizens regardless of social strata. G 



Reference orally absorbed vaccine to control rabies in raccoons. J Amer Vet 

1 UhaaIJ,DatoVM,SorhageFE,etal. Benefits and costs of using an Med Association 1992;201:1873-82. 



1 6 NCMJ / January 1996, Volume 57 Number 1 




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PUBLIC HEALTH 



Encouraging Physical Fitness 
as an Immunization Against 
Chronic Disease 

Edward B. Yellig, MD 



This is a true story: 

Bob Sample, a 38-year-old computer 
programmer, came to me at the request of 
his wife. Although Bob was asymptom- 
atic, his wife was concerned because his 
father had died suddenly in his late 40s. 
Bob was not particularly happy about 
coming for an evaluation, but he obliged 
his wife. He sat at his computer all day 
and had no regular exercise habits. He 
smoked three packs of cigarettes a day 
and ate the ail-American fatty diet. At 5 
feet, 10 inches tall, he weighed an un- 
healthy 235 pounds (body mass index = 
34). His total serum cholesterol was over 
300 with an HDL of 28 and triglycerides 
ofl 230 (the LDL cholesterol could not be 
calculated because the triglycerides were 
so high; see Table ] for normal ranges). 
When I got these abnormal test results, I 
asked him to return so we could plan a 
strategy for lowering his cardiovascular 
risks. 

Two months passed and I did not see 
him. Then I got a call from from Bob's 
wife. Bob had been found dead in bed. 

That story, dramatic but true (except 
that I have changed Bob's name), is far 
too common in our practices and in our 
culture. Atherosclerotic heart disease and 



Dr. Yellig is a physician with Raleigh Inter- 
nal Medicine Associates, PA, Raleigh 
Medical Plaza, 3320 Wake Forest Road, 
Raleigh 27609. 



its associates — stroke, hypertension, and 
peripheral vascular disease — ^are the Four 
Horsemen of the modem American apoca- 
lypse. These disorders alone claim nearly 
50% of the people who die — about one 
million US citizens — every year. They 
are not just diseases of the elderly; more 
than one-third of the deaths occur in people 
35 to 65 years of age, like Bob Sample. 
The costs they engender is staggering. In 
North Carolina alone, they cost almost 
$800 million in 1988, and that more than 
doubled to $1.6 biUion by 1993.' 

The levels of alarm and concern about 
our two epidemics — AIDS and cardio- 
vascular disease — are inversely propor- 
tional to their costs in terms of lives and 
dollars. Perhaps our seeming compla- 
cency about the epidemic of cardiovas- 
cular diseases arises from the very fre- 
quency with which it causes illness and 
death. We are numbed by the sheer num- 
ber of friends, colleagues, and acquain- 
tances who have had heart attacks or 



bypass surgeries. Perhaps heart disease 
has become so commonplace that we no 
longer consider it alarming. Whatever 
the reason, the epidemic is rampant and 
costly in North Carolina and in the entire 
country. Given what we know about our 
youngpeople, the epidemic is morelikely 
to get worse than better.^-' Today our 
children are fatter and less fit than they 
were in 1960, meaning that this cultural 
epidemic has been successfully passed 
on to the next generation. 



The Scope 
of the Problem 

Atherosclerosis is a lifelong process that 
begins in childhood although its signs 
and symptoms do not usually appear until 
the fourth decade of life or later. At birth, 
the average American baby has a serum 
cholesterol of 70 mg/dL, but within six 
months to two years the levels rise to 



Table 1. Glossary of terms 



Term 

total cholesterol 

HDL 

LDL 
Triglycerides 
BMI 



Definition 

total serum cholesterol 
high-density lipoprotein cholesterol 
low-density lipoprotein cholesterol 

body mass index weight (in lbs.) x 705 
height^ 



Normal ranges 

< 200 mg/dL 
> 35 mg/dL 

< 1 30 mg/dL 

< 200 mg/dL 
<25 



18 



NCMJ / January 1996, Volume 57 Number 1 



near-adult concentrations. By age three, 
lipid deposits can be found in the aortic 
walls of some children, and fatty streaks 
appear in coronary arteries by teenage 
years. If we are to achieve primary pre- 
vention of atherosclerosis we must start 
in childhood, not when the patient is 40. 

A number of studies confirm the 
prevalence of coronary risk factors in 
children . Clark et al" studied 4 ,829 school 
children aged six to 1 8 years in Muscatine, 
Iowa. They found a mean cholesterol of 
182, but 24% of values were greater than 
200, 9% greater than 220, 3% greater 
than 240, and 1% greater than 260 mg/ 
dL! Blood pressure elevation to levels of 
adult risk was relatively common; 17% 
of children aged 14 to 18 had either sys- 
tolic or diastolic hypertension or both. 
The authors were surprised that so many 
children were at risk for the development 
of coronary disease. Other studies con- 
firm these findings, but there is still no 
official consensus about cholesterol 
screening in children.^ Nevertheless, the 
epidemiological results support the need 
for regular screening of school-age chil- 
dren, and imply that strong, school-based 
dietary education and fitness training pro- 
grams would be valuable. 

In Norway, Tell and Vellars found 
that cardiovascular disease risk factors 
were inversely proportional to physical 
fitness in children.' Fitness, measured by 
oxygen consumption, was inversely re- 
lated to pulse rate, weight, body mass 
index, skin fold thickness, systolic blood 
pressure, diastolic blood pressure, total 
cholesterol and triglycerides — the more 
fit the children were, the lower were all 
those risk factors. Fitness was positively 
correlated with physical activity, HDL 
concentration, and the ratio of HDL to 
total cholesterol. The most important pre- 
dictor of fitness was lack of obesity (de- 
termined from skin fold thickness in boys 
and body mass index in girls). Interest- 
ingly, Tell and Vellars found that a slow 
resting heart rate was the second best 
predictor and recommended using the 
resting pulse rate as a screening test. 

Because of the long time needed to 
correlate childhood fitness with adult 
cardiovascular disease risk, no such stud- 
ies have been published. However, 



Dennison has compared the physical ac- 
tivity levels of 453 men aged 23 to 25 
with their fitness test scores determined 
at ages 1 to 1 1 and 15 to 18.' Physically 
active adults had attained better fimess 
test scores in their youth — in fact, there 
was a linear relationship between adult 
physical activity and childhood scores on 
the 600-yard run and the sit-up lest. This 
study supports the value of fimess testing 
because it can identify children at risk of 
becoming physically inactive adults. 

In general, it has been easier to relate 
adult levels of physical activity and fit- 
ness to the prevalence and incidence of 
chronic disease and death (both well- 
defined end points).' In a focused article 
published in 1986,' Paffenbarger et al 
reported that death rates declined steadily 
as energy expenditure in physical activ- 
ity increased from 500 to 3,500 kilocalo- 
ries per week (Figure 1, below). This 
benefit of physical activity was indepen- 
dent of subjects' hypertension, cigarette 
smoking, body weight, or heredity. The 
data imply that people gained one to two 
extra years of life from an 
active lifestyle. 

In 1989, Blair et al re- 
ported on more than 1 3, (XX) 
participants who received 
preventive medical evalua- 
tions at the Cooper Clinic in 
Dallas, Texas.'" Maximal 
duration of treadmill exer- 
cise was used to determine 
fitness categories. In both 
men and women, mortality 
rates were highest for those 
in the lowest fitness quintile 
and lowest in the highest 
fitness quintile (Figure 2, 
next page). The least fit men 
experienced 64 deaths per 
10,0(X) person-years com- 
pared to 18.1 deaths per 
10,000 person-years in the 
most fit; rates for women 
were lower, but corre- 
sponded to the male pro- 
files. There was noevidence 
that age, smoking, choles- 
terol level, systolic blood 
pressure, fasting blood glu- 
cose, or parental history of 



coronary disease distorted their findings. 
They concluded that the lowest physical 
fitness level — a sedentary lifestyle— was 
a definite risk factor for all-cause mortal- 
ity. 

In April 1995, Blair et al" reported 
on nearly 10,(XX) participants who had 
been given two preventative examina- 
tions approximately five years apart. Us- 
ing maximal treadmill time to measure 
fitness as in their earlier study,'" they 
concluded that the highest age-adjusted, 
all -cause death rate(122deathsper 10,000 
person-years) occurred in men who were 
unfit at both examinations; the lowest 
(39.6 deaths per 10,(XX) person-years) 
occurred in men who were physically fit 
at both examinations. Furthermore, they 
found that the effect of physical fitness on 
all-cause mortality was dose-dependent, 
so that "for each minute increase in maxi- 
mal treadmill time between examinations 
there was a corresponding 7 .9 % (p= .00 1 ) 
decrease in risk or mortahty." 

Otherresearchers have demonstrated 
the benefit of physical activity on the 



c 
o 

<S 



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o 

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I 

c 
a 
E 

8 

o 
o" 

d> 

Q. 
0) 

a 

s 

+.» 
CD 
O 

■o 

o 
«) 

3 
CB 

V 



relative risks 
above plot points 




100 
80 

60 



40 



20 - 



60-69 





50-59 



35-49 



1 



1 



± 



<500 500-1999 2000+ 

physical activity in kilocalories per week 

Fig 1: Age-specific mortality from all causes among 
1 6,936 Harvard University alumni In 1 962-1 978, accord- 
ing to physical-activity levels." 



NCMJ / January 1996, Volume 57 Number 1 



19 



onset of diabetes mellitus,'' weight 
control,'" osteoporosis," hyperten- 
sion," and lipids." The benefits of 
exercise and physical activity do 
not require high-intensity aerobic 
workouts. Leon et al" and Lakka et 
al" both showed that lower levels 
of leisure-time physical activity 
conferred modest but measurable 
benefits on middle-aged men in their 
study cohorts. In a most unusual 
study, Morris et al found that bus 
conductors who seated passengers 
on the top deck of London buses 
had a lower incidence of CHD than 
those who seating passengers on 
the lower deck (and did not have to 
walk upstairs).'^ 



A Proposal for 
Prevention 



CB 
O 
>< 

C 
O 

9) 

w 
O 

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o 
o 
o 
o" 



70 



60 



50 



40 



? 30 

o 
a 

«2 20 



(0 

o 



10 



64.( 



men 



women 



39.5 



25.5 



27.1 



21.7 



18.6 







20.5 



^ 



i 



6.5 



8.5 



^ ^ 



1 



2 3 4 



least 
fit 



most 
fit 



least 
fit 



most 
fit 



fitness quintlles 



Studies such as those cited above 
have encouraged the Centers for 
Disease Control and Prevention and 
the American College of Sports Medi- 
cine to recommend that "every US adult 
should accumulate 30 minutes or more of 
moderate intensity physical activity on 
most, preferably all days of the week."^ 
In other words, they reccommend that 
men and women be "immunized" with 
daily aliquotsof moderate-intensity physi- 
cal activity to protect against premature 
death from coronary disease and other 
causes. Physicians know too well the 
difficulty of getting their adult patients to 
accept this "immunization." Wouldn't it 
be more effective to "immunize" chil- 
dren in schools by requiring high-quality 
daily physical education? 

The well-documented evidence that 
US children are fatter and less fit than 
children in the 1960s has led to a ground- 
swell of support for school-based health 
education and fitness programs for chil- 
dren. The President's Council on Physi- 
cal Fitness and Health has been promot- 
ing such programs for at least 20 years. 
The Bogaloosa Heart Study led to a 
school-based program call "Heart Smart," 
designed to reduce cardiovascular risk 
factors in children.^' This innovative pro- 



Fig 2: All-cause death rates related to physical fitness level in 13,344 initially healthy 
subjects. Compiled from data in Blair et al.'" 



gram involves the total school environ- 
ment from kindergarten through sixth 
grade. Interventions consist of health in- 
struction, physical activity, and health 
services. Course curricula are designed 
to impart information about the physiol- 
ogy of the body as well as encourage 
physical fitness. The school offers a heart- 
healthy lunch program and requires a 
year-long "Super Kids, Super Fit" pro- 
gram of physical education. All children 
and staff are screened for physiological 
risk factors such as high blood pressure, 
cholesterol, and weight-for-height; spe- 
cial attention is given to high-risk chil- 
dren and parents. 

In 1991, the Wake County Medical 
Society provided seed money to develop 
a pilot project at the A. B. Combs El- 
ementary School in Raleigh. The school 
system provided a full-time physical edu- 
cator, but the faculty and families at the 
school developed their own program . S tu- 
dents receive structured daily physical 
education — once a week from the physi- 
cal education specialist and on other days 
from classroom teachers and area high 
school physical education students. 



In summer 1992, the classroom teach- 
ers undertook a week's training in cardio- 
vascular risk factors, exercise physiol- 
ogy, and the application of health infor- 
mation through the different class sub- 
jects. Parents developed a newsletter and 
participate in physical education programs 
on a seasonal basis. Teachers use a physi- 
cal education notebook which includes a 
monthly guide to fitness, health, nutri- 
tion, and physiology lessons. They use 
aids such as the "American Heart Asso- 
ciation Treasure Chest Kit" and "Foods 
Keep Me Healthy: National Dairy Coun- 
cil Kit." Classroom programs integrate 
physiology with physical education prin- 
ciples. Innovative programs introduce 
heart-healthy foods that appeal to stu- 
dents. One measurable result of the pro- 
gram was that 87% of the 341 students 
enrolled at the school tested at or above 
the state standard for the one-mile run. 
(Unfortunately, parents would not allow 
the students to be weighed, so no weights 
were available for comparison.) 

The challenge for physicians, com- 
munity leaders, health educators, and 
school officials is to design a "vaccine" to 



20 



NCMJ / January 1996, Volume 57 Number 1 



be used in all schools, all grades. By 
"vaccine" I do not mean a one-time shot 
in the arm, but rather the daily adminis- 
tration of small aliquots of information 
and activities designed to attractand make 
children comfortable with being healthy 
and fiL The process by which we will 
reach such a goal may be long, complex, 
and expensive — but it may actually save 
money and will certainly be healthier for 
our country in the long run. 

The Wake County Medical Society's 
role in developing its pilot project re- 
quired presentations to the Wake County 
School Board, the Wake County Com- 
missioners, the Wake County Board of 
Health, numerous PTA organizations, the 
Public Health Committee of the Wake 
County Medical Society, and the body of 
the county Medical Society itself. It took 
three years from the start of educational 
presentations until the pilot project began 
in fall 1992. However complicated, the 



process resulted in positive changes at 
Combs Elementary, within the students, 
and within the parents. These included: 

• The program paired nutrition with ex- 
ercise and urged teachers to relate their 
classroom work to health issues dis- 
cussed in health and physical educa- 
tion classes. 

• Cafeteria staff introduced heart-healthy 
foods to students in interesting ways. 

• Parents contributed recipes for the 
"Combs Elementary Cookbook." 

• Using materials developed with grant 
funds, teachers emphasized life-long 
fitness activities during recess. 

• The school principal reported fewer 
behaviorproblems, increased attention, 
and improved interaction between stu- 
dents and teachers following the pro- 
gram. 

• Items sold for school fundraisers in- 
cluded less candy and more healthful 



foods than in previous years. 
• Parents participation increased in 

school-sponsored health fair events. 
Extending this program to other el- 
ementary schools, middle schools, and 
high schools will require a re-visioning 
of the public's priorities, including the 
relative value of courses designed to im- 
prove the competitiveness of students 
applying for college admission. Physical 
education and physical fitness may seem 
less urgent, less pertinent than mathemat- 
ics, sciences, and the arts, but "life" is as 
important as "living." We need innova- 
tive programs like that at Combs Elemen- 
tary as well as efforts by physicians, 
teachers, parents, interested politicians 
and community leaders. Unless we get it, 
a large group of vulnerable children, soon 
to become adults, will raise the epidemic 
of cardiovascular disease to unbearable 
proportions. Q 



References 

1 North Carolina Data Bank Commission, 
report, November 24, 1994. 

2 Ross JG, Gilbert GG. The national chil- 
dren & youth fitness study . The Journal of 
Physical Education, Recreation, and 
Dance 1985;(Jan.):45-90. 

3 Ross JG, Pate RR. The national children 
& youth fitness study U. The Journal of 
Physical Education, Recreation, and 
Dance 1987;(Nov.-Dec.);51-96. 

4 Clark WR,SchTottHG,LeavertonPE,et 
al. Tracking of blood lipids & blood pres- 
sures in school age children. The 
Muscatine study. Circulation 1978;58; 
626-34. 

5 Lauer RM, Conner WE, Leaverton PE, et 
al. Efficacy and safety of lowering dietary 
intake of fat and cholesterol in children 
withelevated low-density cholesterol, die 
dietary intervention study in children 
(DISC). JAMA 1995;273: 1429-35. 

6 TeU GS, VeUars OD. Physical fitness, 
physical activity, and cardiovascular dis- 
ease risk factors in adolescents: the Oslo 
youth study. Prev Med 1988;17:12-24. 

7 Dennison BA, Straus JH, Mellitts ED, et 
al. Childhood physical fitness tests: pre- 
dictor of adult physical activity levels? 
Pediatrics 1988;82: 324-30. 



8 Various authors. Workshop on epidemio- 
logic aspects of physical activity and ex- 
ercise. Public Health Reports 1984; 100: 
113-224. 

9 Paffenbarger RS Jr, Hyde RT, Wing AL, 
et al. Physical activity, all-cause mortal- 
ity, and longevity of college alumni. N 
Engl J Med 1986;314:605-13. 

10 Blair SN, Kohl HW IB, Paffenbarger RS 
Jr, et al. Physical fitness and all-cause 
mortality. JAMA 1989;262: 2395- 401. 

11 Blair SN, Kohl HW in. Barlow CE.etal. 
Changes in physical fitness and all -cause 
mortality. JAMA 1995; 273:1093-8. 

12 Morris JN, Kagan A, Pattison DC, et al. 
Incidence and predication of ischemic 
heart disease in London busmen. Lancet 
1966;2:553-9. 

13 HelmrichSP,RaglandDR, Leung RW,et 
al. Physical activity and reduced occur- 
rence of non- insulin -dep-endent diabetes 
mellitus. N Engl J Med 199 1 ;325 : 147-52. 

14 Pacy PJ, Webster J, Garrow JS. Exercise 
and obesity. Sports Med 1986;3:89-113. 

15 Snow-Harter C, Marcus R. Exercise, bone 
njineral density, and osteop»rosis. Exerc 
Sport Sci Rev 1991;19:351-88. 

16 Blair SN, Goodyear NN, Gibbons LW.et 
al. Physical fitness and incidence of hy- 



jjertension in normotensive men and 
women. JAMA 1984;252: 487-90. 

17 TranRV.Weltman A. Differential effects 
of exercise on serum lipids and lipopro- 
tein levels seen with changes in body 
weight. A meta-analysis. JAMA 1985; 
254:919-24. 

18 Leon AS, Connett J, Jacobs DR, et al. 
Leisure time physical activity levels and 
risk of coronary heart disease and death. 
JAMA 1987;258: 2388-97. 

19 Lakka TA, Venalainen JM, Rauremaa R, 
et al. Relation of leisure-time physical 
activity and cardiorespiratory fitness to 
the risk of acute myocardial infarction in 
men. N Engl J Med 1994; 220:1549-54. 

20 Pate RR, Pratt M, Blair SN, et al. Physical 
activity and public health, a recommen- 
dation from the Centers for Disease Con- 
trol and Prevention and the American 
College of Sports Medicine. JAMA 
1995;273:402-7. 

21 Downy AM, Cresanta JL, Berenson GS, 
et al. Cardiovascular health promotion in 
children: heart smart and the changing 
role of physicians. Am J Prev Med 
1989;5:279-95. 



NCMJ / January 1996, Volume 57 Number 1 



21 



A PIECE OF A NORTH CAROLINA DOCTOR'S MIND 



Death Worship, Carolina Style 



Gregory J. Davis, MD 



I was driving south on Silas Creek Parkway in Winston-Salem, 
taking my son to school, chatting happily as we motored along. 
Suddenly, there was a car on my tail, literally inches from my 
rear bumper. I could clearly see the young driver's face, 
contorted with fury, as he screamed for me to "hurry up," his 
body a convulsion of impatience. I was traveling at the speed 
limit and was in the right, slow lane, but I obviously did not fit 
into his timetable. As he saw his opening, he jerked the wheel 
and sped past us in the left lane, bestowing upon my young son 
and me an obscene gesture. A half mile down the road, I pulled 
up behind him at a red light, his haste obviously for naught, and 
noted with irony the peace symbol sticker on his rear bumper. 

Though my threechildren sometimes condescendingly see 
their Dad as an old fogey, I consider myself to be a young 37. 
But events in my professional and, as described above, personal 
life of late have me befuddled. I mutter likean elderly curmudg- 
eon about my perceptions of the fraying of our social fabric. It 
is a fraying that, unfortunately, shows no signs of abating, and 
I believe, will keep police, emergency departments, and medi- 
cal examiners such as I busy in years to come. 

After 10 years of performing death investigations and 
forensic autopsies, 1 am often asked what factors contribute 
most to tragically truncating the lives of our citizens. My answer 
is always the same: booze and drugs; guns; speeding motor 
vehicles; short tempers. If a harbinger of decadence in a society 
is the loss of social graces and a love of violence and bloodsport, 
we — as happened to civilizations of bygone era, screaming for 
blood, worshiping death — are well into societal decline. The 
symptoms of the disease are widespread and, again ironically, 
instead of addressing the underlying disease or even offering 
symptomatic treatment, our culture's worship of death only 
exacerbates the process. 



Dr. Davis is Assistant Professor, Department of Pathology, 
Bowman Gray School of Medicine, Medical Center Boulevard, 
Winston-Salem, NC 271 57, Medical Examiner, Forsyth County, 
and Regional Forensic Pathologist, State of North Carolina. 



Witness our federal government acceding to the idea of 
eliminating federally mandated speed limits. Automotive speed, 
often in conjunction with ethanol, causes more than 50,000 
deaths in our country per year. In our pointless rush and inability 
to tolerate delay for even a few moments we seem willing to 
offer up human sacrifices to the god of expediency. 

Witness the cries of "Blood! Blood! Blood!" reported by a 
Winston-Salem Journal reporter describing her experiences at 
the Worid Combat Championship bare knuckles "hand to hand 
combat tournament" recently at Joel Coliseum. 

Finally, witness the insanity of our state's new concealed 
carry law . As of December 1 , 1 995 , citizens are allowed to carry 
concealed firearms despite the fact that of almost all chiefs of 
police in our state are opposed to that law, and for good reason. 
Allow this medical examiner a prediction: Our era has a dearth 
of the social lubricant of good manners, but an abundance of the 
frayed nerves and short tempers common to our everyday life. 
The added variable of allowing individuals to carry guns simply 
because they want to bodes ill for us all. Now, instead of raised 
voices and middle fingers, we will have raised guns. An elderly, 
anxious pedestrian, unnerved by a "suspicious-looking" youth 
walking behind him, will nervously reach for his gun in order 
to "protect" himself. Tragedy will ensue. Robert Heinlein, the 
former naval officer and science fiction writer, told his faithful 
fans that an armed society was a pohte society. That romantic 
vision, if it were ever valid, is certainly no longer so; good 
manners are no longer a constant in our social intercourse. 

Our emergency departments, trauma services, law en- 
forcement officials, and medical examiners, busy as they are 
already, will become more so. Siu^e, stiff penalties have been 
created by the General Assembly for brandishing a weapon, but 
Pandora's box, once opened, is not easily closed. In the heat of 
anger or the cold grip of fear, penalties will not be considered. 
Anger and fear always dull sensibilities. 

To a greater or lesser degree, bloodlust has always been an 
enemy of the health and well-being of our patients, but never 
before has it received such official sanction. Our days on this 
Earth are brief enough. Our collective passion for violence and 
worship of death leaves this North Carolina doctor perplexed. □ 



22 



NCMJ / January 1996, Volume 57 Number 1 



A Commitment to Change. 
A Commitment to You. 




The physicians of North Caroline planted the seeds of change in 1975 when they 

formed Medical Mutual Insurance Company. For 19 years, health-care providers in 

the Tar Heel state have been reaping the benefits of their physician-owned and 

operated company. At Medical Mutual, we're committed to change. 

We're committed to you. 



Medical Mutual Insurance Company of North Carolina 

919.872.7117 800.662.7917 
Offices in Raleigh, Greensboro, Greenville and Charlotte 



FICTION BY PHYSICIANS 



Deliverance 



Richard B. Weinberg, MD 



Bo Taggett was very explicit about his wife's code status: "If 
Ella Jo dies, I'll blow your goddamn head off." 

I believed him. Not so much because he looked like the 
villain in a bad western. Or because he was perpetually drunk. 
Or because I had heard frightening stories about his violent 
behavior. But because there was something inhuman about his 
eyes. His cold, predatory stare cut clear through you as if you 
weren't there at all. 

My problem was that Ella Jo was already dead — except for 
her heart, which had defiantly kept beating through a massive 
intracerebral hemorrhage, renal failure, and ARDS. But now, 
after six months in the intensive care unit, her once steady heart 
was faltering. Several times a day her cardiac monitor alarm 
would sound and the staff would descend in a frenzy on her 
bloated, bruised body. At first, low-energy defibrillation had 
been effective, but the codes were lasting longer and longer. 

"Thank God! I'm outta here!" exclaimed my fellow resi- 
dent when I took over Ella Jo's care. "Her husband's a psycho- 
path!" I met him soon enough. 



"So, you're Ella Jo's new doctor?" Bo Taggett sneered at 
me as I went to meet him in the ICU waiting room. 

"Yes, sir." 

"Well then, you listen and listen good, boy, cause I'm 
gonna tell you only once. You do everything you gotta do to 
keep Ella Jo alive. Breathing machines, kidneys machines, 
poundin' on her chest, whatever it takes, you do it!" 

At first I thought that Bo's posture was that of a grieving 
husband unable to accept his wife's catastrophic illness. But he 
did not seem to care about her personally. He never visited her 
bedside, never held her hand. He just appeared in the waiting 
room, belligerently demanding reports on her status. My at- 
tempt to explain the futility of further extreme measures had 
resulted in his threat to my hfe. And soon I had real cause to 
worry. 



Dr. Weinberg is Professor and Chief, Section of Gastroenterol- 
ogy, Department of Internal Medicine, Bowman Gray School of 
Medicine, Winston-Salem 27157-1048. 



The next morning I woke with a start at 4 a.m. I listened and 
at first heard nothing, but then noted a low rumble outside my 
window. I pulled back the shade and saw a pickup truck parked 
on the street in back of my apartment The light was on in the 
cab, and inside, beneath a gun rack loaded with more firepower 
than would ever be needed on a hunt, sat Bo Taggeu, carefully 
cleaning his nails with a pocketknife. The message was clear — 
he knew where I lived. 



My first business that moming was with the chief of 
hospital security. "That Bo Taggett's a mean cuss all right, but 
there's not much we can do about him unless he physically 
harasses you." 

"But he threatened to kill me! Can't you arrest him or at 
least keep him out of the hospital?" 

" Wouldn ' t help much. If I called the cops to arrest him , it'd 
j ust be your word against his. He'd be back here before the day 's 
out" 

"But he punched out Ed Billings in the parking lot last 
month." 

"Yes, he did. But Billings wouldn't press charges — I think 
Bo's got him good and spooked." 

I thought of Ed, his wife, their infant daughter, and won- 
dered if Bo had paid their townhouse an early moming visit, too. 

"Now 1 didn't say this, son, but the easiest way for you to 
handle this is to just keep that woman alive until the end of the 
month — then it'll all be someone else's problem." 



The next code lasted over an hour, and it was a grisly affair 
of cracked ribs, chest tubes, and enough joules to peel the skin 
off her chest. As I pumped Ella Jo's chest in a sweat and barked 
orders to the nurses, a wave of moral nausea suddenly overcame 
me: I wasn 't keeping her alive because I thought she would ever 
recover — there was no chance of that; I was keeping her alive 
for a cowardly reason — I was afraid for myself. 

A stable rhythm returned. I slumped down in the nurse's 
station, exhausted and shaken. As I despaired over my predica- 
ment a pair of strong hands began to knead the knots in my neck. 



24 NCMJ / January 1996, Volume 57 Number 1 



"You have the hands of an angel. Pricey." 

Pricey Pender was one of the people who made the ICU 
endurable. She had grown up on a ranch in north Texas and had 
a cowgirl's weathered beauty and no-nonsense manner. She 
also had a mysterious aloofness that attracted considerable 
interest from the male house officers. In the eyes of her 
co-workers, she was crazy to have turned down so many 
grade-A suitors, but she gave no reasons. "I've been on that 
cattle drive," was all she would say. I had met her during my first 
ICU rotation, and we had become friends. 

"What's the matter, honey? Your neck's as tight as a 
barbed wire fence." 

"Why is he doing this? Is he some kind of sadist?" 

"Who? Bo Taggett? Why, he isn't doing anything different 
now from what he did to her before she got sick." 

"What do you mean?" 

"I grew up in Harvey County. Everybody there knows that 
poor Ella Jo Taggett is the most abused woman in all of Texas. 
My cousin Ed's a sheriff's deputy, and he could tell you stories 
about Bo that would give you the willies. The sad thing is that 
when he's not beating her, he wouldn't lift a finger for her — 
almost a point of pride. If she were bleeding to death he 
wouldn't give her a drop of his blood." 



" '...when he's not beating her, 

he wouldn't lift a finger for her,,.. If she 

were bleeding to death he wouldn't 

give her a drop of his blood.' " 



"Why didn't she just leave him?" Pricey 's hands tightened. 
"Oww." 

"Sorry. Loneliness, hopelessness, fear. . . ," she said with a 
sad air of authority. 

"So, how do you deal with someone like that? 

"Like a horse. A horse will test you first time you ride him, 
and if he senses you're afraid, he'll throw you first chance he 
gets. And if you don't get right back in the saddle and show that 
horse who' s boss, you'll never be able to ride him again. A horse 
may be bigger and stronger than you, but he's not smarter. 
There — now your neck's as good as new," she declared, mov- 
ing off to tend to her patients. 



I returned to Ella Jo and her newest problem. She had 
developed a gastrointestinal bleed, and cross-matching her 
blood was proving very difficult. As I waited on the phone to 
talk to the blood bank. Pricey 's words kept running through my 
mind — something she had said was the key to my dilemma. 
Suddenly, with stunning clarity, I knew. A quick trip to check 
on Bo Taggett's chart in the record room assured me that my 



plan had the needed touch of credibility. I found Bo in the 
smoking lounge. 

"We're in a tough situation, Mr. Taggett. Ella Jo's bleeding 
internally again, and she'll bleed to death if we don't give her 
a transfusion. The problem is, it's very hard to find blood that 
matches hers. But you have the right type. I can arrange for you 
to give a donation for her right now. 



"I reflected on how often 

our most powerful tools were 

the hard lessons of life," 



"I ain't bleeding for no one — give her someone else's 
damn blood." 

"I'm sorry, Mr. Taggett, she's got a very rare blood type, 
and right now only your blood can save her. It's your choice. If 
you won't help her, there's nothing I can do." Bo glared at me 
as if he were about to attack, but I held his angry stare. 

"Goddamn!" he screamed, and stomped off down the 
corridor. 

Bo never showed up at the blood bank, and he didn't appear 
in the ICU the next day. I had gambled correctly. That night 
when Ella Jo again slipped into ventricular fibrillation, I ran to 
her bedside and waved off the code team. Ella Jo died quietly. 

•■••••••••••• 

Pricey insisted that she be the one to prepare the body. 
When she emerged from behind the ciulain I saw that she was 
crying. 

"They're all cowards!" she cried. "Weak men who have to 
run a woman down to feel tall. They want control — but not 
responsibility. And we put up with so much pain hoping for just 
a huJe scrap of love," she sobbed. Our eyes met, and she saw the 
question I was afraid to ask. 

"I was just out of high school, and I was so in love with him. 
He made me feel like a queen. But he changed so fast after we 
got married — first the drinking, then the yelling, then the 
hitting. That could just as well have been me behind that 
curtain," she whimpered. 

"But you remembered your riding lessons," I consoled her. 

A wan smile broke through her tears. "Yes. One day, I just 
got tired of being hurt." She sighed. "I'm going to take Ella Jo 
downstairs — I don't want to leave her alone right now." 

I watched Pricey depart with the enshrouded gumey. The 
unit became strangely quiet; the softly beeping monitors re- 
minded me of crickets chirping after the passage of a violent 
summer storm. I reflected on how often our most powerful tools 
were the hard lessons of life. And I marveled that Pricey had 
transcended her misfortunes to come to a place where her little 
acts of love could ease so much pain. □ 



NCM J / January 1 996, Volume 57 Number 1 25 



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^ ^? ^ NORTH CAROLINA MEDICAL SOCIETY 

Health Watch 




AHENTION DEFICIT HYPERACTIVITY DISORDER 

by Barbara Hollandsworth Smith, MD 



The name for Attention Deficit Disorder has changed a 
number of times, creating frustration for patients who have 
to learn new terminology every three to four years. The most 
recent term to describe this disorder is attention deficit 
hyperactivity disorder (ADHD). The label attempts to de- 
scribe the fact that psychiatrists and other specialists in this 
area now feel there is a range of ADHD with poor attention 
being at one end and hyperactivity being at the other. The 
diagnosis apparently can fall anywhere along that continuum. 



Criteria 

The criteria for ADHD, according to recent definition by the 
psychiatric book describing various disorders, the Diagnos- 
tic and Statistical Manual for Mental Disorders, includes two 
dimensions with nine symptoms. Dimensions range from 

Barbara Hollandsworth Smith, MD, is a child psychiatrist 
ajfiliatedwith Charter Behavioral Health Systems in Greens- 
boro. Currently she is the director of a private practice. 
Child Psychiatry Associates, and is a consulting child psy- 
chiatrist with the High Point Mental Health Center. 



inattention to the hyperactivity and impulsiveness. Diagno- 
sis also requires onset before age seven, duration of six 
months, and impairment in at least two settings — home, 
schoolwork, social. 

The child who is inattentive is likely to show the follow- 
ing symptoms: 

• fails to pay or sustain attention 

• difficulty listening 

• does not follow through on instructions 

• difficulty organizing 

• difficulty with sustained mental effort such as schoolwork 
or homework 

• often loses things 

• easily distracted 

• often forgets daily activities. 

The child who is hyperactive is likely to show the 
following symptoms: 

• fidgets often 



NCMJ / January 1996, Volume 57, Number 1 



27 



• leaves seat in the classroom 

• often runs about or climbs 

• often has difficulty playing or engaging in leisure activities 
quietly 

• often acts as if "driven by a motor" 

• often talks excessively. 

In additional there are three symptoms highlighting 
impulsive children including: 

• blurts out answers before questions have been completed 

• has difficulty awaiting turn 

• interrupts or intrudes on others (for example during con- 
versations or games). 



Related Disorders 

Other psychiatric disorders are likely to be seen in children 
with ADHD. An associated oppositional/defiant disorder 
and conduct disorder, both of which are reflected by acting 
out behaviors, is very high. Children with these combina- 
tions are at increased risk for substance abuse whereas 
children with just pure ADHD are not. The coexistence with 
other disorders such as learning disabilities, the mood disor- 
ders of depression and manic depression, and anxiety disor- 
ders is also very high. 

Finally, these children frequently lack the ability to 
relate in a socially appropriate manner with peers and others 
due to their impulsiveness, distractibility, intrusiveness and 
low tolerance for frustration. 

The negative feedback they get from social interactions 
results in low self-esteem and feelings of worthlessness, 
which can lead to a depression. The symptoms can worsen as 
the child moves to more difficult schoolwork in the higher 
grades, especially as they reach third and fourth grades. 



Causes 

Psychiatrists are aware that a number of factors contribute to 
this disorder. Genetic factors play a part and research shows 
there is increased ADHD in people with family members 
who have what we now call ADHD. Other factors 
contributing to the disorder include brain trauma and 
infection as an infant or young child. Children with lead 
poisoning, malnutrition, low birth weight, prematurity, 
birth complications, and exposure to cigarettes, alco- 
hol and drugs during pregnancy are also at greater risk 
for ADHD. 

Parents often ask whether children at risk for the 
disorder should avoid certain foods. Although a 
controversial area, psychiatrists have found no evi- 



dence that diet or allergies contribute to ADHD. Often 
parents will state that their child is more hyperactive after 
eating certain foods. A rule of thumb in this situation is to 
recommend that they not have their child eat these specific 
foods. Otherwise, there are no specific dietary recommenda- 
tions or restrictions. , 

Generally , child psychiatrists are able to diagnose ADHD 
as early as the toddler age. At this age, it is best to treat with 
changes in the environment only if possible. However, some 
children have been treated as young as age three when severe 
ADHD was disrupting their ability to function or placing 
them in danger due to their extreme hyperactivity and impul- 
siveness. 



Who is Affected? 

ADHD is a common disorder in the population. Nine percent 
to ten percent of boys and 3% of girls are known to be 
affected. Less is known about ADHD in girls. They tend to 
have less hyperactive symptoms and less aggression but 
increased attention, learning, anxiety, mood and language 
problems. Often girls do not get referred to a doctor, 
evaluator or clinic because they are less hyperactive and 
therefore less disruptive in classroom and social settings. For 
this reason, it tends to be diagnosed later in girls. 



In the past, it was commonly believed that ADHD was 
only a disorder of younger children. However, research 
statistics and improved knowledge about this disorder tell us 
that ADHD persists into adolescence almost 1 00% of the 
time. It persists into adulthood approximately 70% of the 
time. Adult ADHD is quite common, although many of these 
people have successfully compensated for this problem. 

The outcome of ADHD in children without treatment is 
poor. This disorder can have serious negative consequences 
in the academic and social arena, often resulting in damaged 
self-esteem in a child who later may develop a secondary 




28 



NCMJ / January 1996, Volume 57, Number 1 



depression. Results of untreated ADHD include school 
failure and dropout, anti-social behavior, automobile acci- 
dents, and substance abuse if they have an associated conduct 
disorder. As indicated above, depression and impulsive 
suicide attempts exists in children, adolescents and adults 
who suffer from ADHD. It frequently has to be treated as a 
separate illness. It is not uncommon for children or adoles- 
cents to be on both a Ritalin-type medication and an anti- 
depressant. 



Diagnosis 



Parents often ask if there is a blood test or other way to 
determine whether their child or adolescent has ADHD. No 
specific laboratories tests, CT scans or MRI can help pinpoint 
the problem. A thorough history, including family history of 
ADHD symptoms and those diagnoses that are often seen 
together with ADHD, is essential. In addition, parent and 
teacher rating scales, such as the Conners Rating Scale, are 
useful in confirming the diagnosis. Children, especially 
younger ones, generally deny symptoms and there is little 
yield from having them fill out rating scales, although adoles- 
cents and adults often give helpful self reports. The decision 
to treat a patient for ADHD should be made by a qualified 
psychiatrist after a careful diagnostic evaluation. Too often, 
parents or teachers inappropriately demand that a very active 
child be treated. Treating ADHD involves many different 
interventions. These include teaching parents to control and 
redirect impulsive/negative behaviors and educational inter- 
vention with school staff to help them deal appropriately with 
the child. Sometimes, individual and family therapy is also 
helpful, especially if there are other problems in addition to 
the ADHD. Medication should be used judiciously and is 
usually only necessary in moderate to severe cases of ADHD. 
This accounts for about 20% of all cases. 

The most common medications to treat ADHD are 
stimulants. The brain has two kinds of nerve fibers, excita- 
tory and inhibitory. In patients with ADHD, the inhibitory 
nerve fibers are sluggish or asleep and need to be stimulated. 
Stimulants such as long-acting and short-acdng Ritalin, 
Dexedrine (including the more long-acting Dexedrine 
Spansules and the short-acting Dexedrine tablet), and Cylert 
(Pemoline) may be prescribed. Often, the choice of stimulant 
is based on the side effects of each medication. For example, 
Dexedrine seems to cause more appetite suppression in 
younger children. Even though they have similar side effects, 
it is not uncommon for a patient having difficulty on one 
stimulant to do well without side effects when switched to 
another. 

Patients and parents are encouraged not to become 
frustrated if the medication trial is not successful. There are 
many options to choose from, and sometimes a trial of 



several different medications is needed to find the most 
appropriate treatment. 

Some psychiatrists routinely start with Ritalin. The 
long-acting form of Ritalin is not very effective without the 
additional short-acting forms. They are frequently used 
together. Many doctors now prefer Dexedrine as their first 
stimulant of choice. The long-acting Dexedrine Spansules 
remain in the system for about eight hours at their optimum 
and are very effective. Cylert is given on a once-a-day basis, 
which provides much benefit especially for the child who 
does not want to take medication at school. However, this 
positive aspect is counter-balanced by the negative of having 
blood drawn every six months to monitor liver function, even 
though liver damage rarely occurs. 



ADHD is a common disorder — 

9%- 70% oi boys and 3% of girls 

are Icnown to be affected. 



Stimulants have been used for many years in children 
and are safe and effective. Side effects can include decreased 
appetite, weight loss, upset stomach — which usually re- 
solves if taken with a small snack— and difficulty falling 
asleep. When there is a side effect, often a change to a 
different stimulant is sufficient to resolve the problem. An 
additional problem with the stimulants involves a rebound 
irritability and nervousness as the medicine is withdrawing 
from the system. In this case, it is best to move smaller doses 
closer together, for example, every three hours rather than 
every four hours. 

Many patients are concerned about the addictive poten- 
tial of stimulants. Dosage usually prescribed are not addic- 
tive, and as long as the drugs are used properly they should not 
be a problem. If there is an addiction problem present in the 
individual being treated, Cylert may be the best choice since 
it is non-addictive. 

Other treatments for ADHD include the tricyclic (for 
example Imipramine and Desipramine), Wellbutrin, as well 
as the rarely used MAO inhibitors (for example Nardil). 
Recently, however, there has been some concern about 
negative side effects with this combination and until further 
research is being done some doctors have abandoned this 
combination. It is important to treat other conditions that may 
exist like depression, other mood disorders, or Tourette's 
Syndrome. Multiple medications are a frequent mode of 
treatment in all age groups these days. For example an anti- 



NCMJ / January 1996, Volume 57, Number 1 



29 



depressant such as Zoloft may be used in combination with a 
stimulant such as Dexedrine or Ritalin. 



Behaviors 

Because ADHD persists into adulthood approximately 70% 
of the time, the symptoms may manifest in different ways. 
For example, low frustration tolerance, shifting activities, 
boredom, impatience, irritability, and mood swings. It is 
helpful to have a "significant other" document the adult 
symptoms. Spouses often motivate, encourage, or demand 
that their husband or wife be evaluated for this problem. 

Another group of young adults who refer themselves are 
college students who have the inattentive spectrum of ADHD 
and are feeling disorganized by their large amount of school- 
work. It is important to document a childhood history of 
ADHD if at all possible. This can sometimes be done by 
getting information or having forms filled out by the adults 
parent or older siblings. Another valuable resource is looking 
at old report cards to see teachers' reports on behavior and 
conduct. 

As in children, other psychiatric disorders are fre- 
quently present in adults with ADHD. Major depression 
exists in 17%-3]% of cases, bipolar disorder ormanic depres- 
sive disorder in 5%-10% of cases, anxiety disorders in 20%- 
50% of the cases, especially females. 

Substance dependence is a frequent problem that is 
found in adults with ADHD: alcohol abuse in 27%-36% of 
the cases and drug abuse in 20% of the cases. This last group 



of patients presents somewhat of a dilemma in treatment 
given that the stimulants Ritalin and Dexedrine also can 
potentially be used in an abusive manner. Cylert may be used 
for this population. 

Treatment for adult ADHD usually involves a combina- 
tion of medication management and other therapies. The 
stimulants Ritalin, Dexedrine and Cylert are very effective. 
On infrequent occasions, adolescents have abused medica- 
tions or allow their friends to do so. 



The decision to treat a patient 

for ADHD sliouid be made 

by a qualified psychiatrist. . . . 

Too often, parents or teachers 

inappropriately demand that 

a very active child be treated. 



It is critical that patients be evaluated and treated for 
other conditions that may exist along with the ADHD such as 
depression or other mood disorders . Therapists are available 
in the community to treat adult ADHD and help change 
maladaptive behaviors that have developed over the years. 
This is usually very goal-directed and time- limited treat- 
ment. These may be recommended in conjunction with a 
medication program. □ 



30 



NCMJ / January 1996, Volume 57, Number 1 



HEALTH IN THE WORKPLACE 

Violence and Work Injury 

A Revealing Look at Turbulent Times 



Anthony H. Wheeler, MD, and Robert D. Ruth, PhD 



Violence in America is on the rise. 

Violence has spanned the history of humankind. It has 
formed a common link between cultures and ethnic groups. We 
do not know whether aggression is genetic or learned, but we do 
know that all animals acquire this trait to ensure survival, 
territorial rights, and sexual dominance. However, in most 
animals — except humans — aggressive behavior ceases with 
victory or resolution of threat. The causes of human violence 
can be ascribed to endogenous (biological) or exogenous 
(psychosocial) factors (Table 1, next page).' 

Violence is endemic throughout American society and 
usually occurs between individuals or groups who know each 
other, often coworkers. The statistics about violence at woilc 
are staggering. The National Institute of Occupational Safety 
and Health found that homicide accounted for 12% of deaths in 
the workplace between 1980-1988, a figure exceeded only by 
transportation and machine-related work injuries.^ In 1992, 
there were 110,0(X) incidents of workplace violence in the 
United States, and 1,004 worker deaths, of which 24% were in 
managerial or administrative support personnel.' In both 1992 
and 1993, homicide was the second leading cause of workplace 
death.* In 1993, traffic accidents and workplace violence were 
the leading causes of death in North Carolina (Table 2, next 
page);^ 54 of 214 fatal occupational injuries were due to 
homicide or suicide, second only to transportation as a cause of 
death.' 

Workers in commercial settings were at highest risk, but "a 
sizable proportion of the victims of nonfatal violence were 
caregivers in nursing homes and hospitals" who were assaulted 
by patients.' In 1992, workplace violence cost American busi- 
ness approximately $4.2 billion.^ 

Usually violence is the result of outside problems spilling 
over into the workplace — for example, the nighttime robbery of 
a convenience store. However, workplace conflict can turn into 

Dr. Wheeler is an Orthopedic Neurologist at Charlotte Orthope- 
dic Specialists, 1915 Randolph Road, Charlotte 28207. Dr. Ruth 
is Associate Professor of Sociology at Davidson College. 



real violence such as the shooting sprees of angry postal 
workers in CaUfomia and Michigan. The senseless bombing of 
the federal building in Oklahoma City has made it apparent that 
our homes and workplaces are no longer safe. Americans are 
concerned. Though such events are not yet commonplace, 
employers and employees must recognize the potential for 
violent responses created by a changing economy, corporate 
downsizing, reinventing jobs, and the evolving character of our 
modem workforce. 

Job terminations, whether due to economic factors or 
performance issues, may lead to acts of anger or workplace 
violence by disgruntled former employees. Companies that are 
downsizing or restructuring are well advised to use consultants 
and mediators to minimize the adverse effects on workers who 
are laid off and the morale of workers who remain. 
"Post-mortem" evaluation of workplace incidents often reveals 
that management has responded poorly lo employees' needs 
and concerns. Causes of violent acts in the workplace should be 
assessed and ways sought to prevent repetition. Education, 
debriefing, and counseling programs can help workers who 
have experienced physically or emotionally traumatic events.' 

Ciurendy, North Carolina has an increasing number of 
foreign-bom workers. There are factories in Charlotte where 
workers speak five different languages. Employee relations 
must pay attention to cross-cultural issues, including attitudes 
about ethnicity, interpersonal relations, and the prevalence of 
violent and aggressive behaviors. Management must not only 
understand these issues, but secure the workplace for its em- 
ployees.' 



Workplace Security: 
Limiting Exposure^'^ 

Four axioms relate to security in the workplace: 

1. Communication. When threats are made, employers 
and supervisors must listen. Employee frustration and anger 
must be recognized and communication established. In North 



NCMJ / January 1996, Volume 57 Number 1 



31 



Carolina, most employers can fire employees at will. Summary 
dismissal can affect employees emotionally and even threaten 
the survival of some. Employee assistance programs and other 
forms of employee mental health assistance should be available 
as a matter of protocol. These programs should provide educa- 
tion and counseling about the recognition and management of 
stress and substance abuse, prevention of personal crises, and 
the recovery from trauma. 

2. Architecture and policy design. Ample outside lighting 
secures pedestrian and parking areas. Access to parking lots and 
buildings should be monitored by guards or pass-card so that 
workers are protected from the potential for outside disputes 



Table 1. Human violence: proposed etiologic factors (examples in 
parantheses) 



I. ENDOGENOUS INFLUENCES 

A. Neurological 

1 . Focal brain disorders (temporal lobe "dyscontror) 

2. Diffuse brain disorders (encephalopathy, dementia) 

a. post-traumatic injury 

b. metabolic (organ or substrate failure) 

c. toxic or drug-related (acute intoxication, 
chronic residua) 

d. infectious (encephalitis, meningitis) 

e. vitamin deficiency 

f. degenerative (Alzheimer's, Parkinson's diseases) 

g. congenital (mental retardation) 

h. other acquired (stroke, tumor, etc.) 

B. Psychological 

1 . Neurotransmitter disorders (increased catecholamines 
or decreased serotonin) 

2. Psychoses (schizophrenia, paranoid or mood disorders) 

3. Personality disorders (antisocial, borderline) 

4. Behavior disorders (conduct or attention deficit disorders) 

C. Genetic 

1 . Chromosomal (XYY syndrome, monozygotic twins) 

2. Metabolic (porphyria, Wilson's disease) 

II. EXOGENOUS INFLUENCES 

A. Alcohol and drug abuse 

B. Developmental factors 

1. Socialization 

2. Physical or sexual abuse 

3. Attitudes about violence 

C. Social structure 

1 . Socioeconomic factors (deprivation, opportunity) 

2. Social disorganization (disruption of the nuclear family) 

3. Delinquent or deviant subcultures 

D. Social process factors 

1. Social learning and exposure to violence 

2. Social control mechanisms 

3. Labeling and differential enforcement 

E. Physical factors 

1. Heat, environmental contaminants 



overflowing into the workplace. Entrances and walk areas 
should be clear of obstructions. Escorts and seciuity patrols 
should be used when indicated. A "buddy system" for employ- 
ees at risk assigns personal responsibility and may alleviate 
some employer liability. Also, employees should be reminded 
of their responsibility to notify security of any potential for 
violence. A lockable "safe room" equipped with a cellular 
telephone can provide a secure location where threatened 
workers can wait for help. 

3. Hire well. Pre-employment checks regarding previous 
unacceptable behavior, violence, or a migratory work history 
can identify potential risks. All character references should be 
checked. AppUcants should be told they will be 
drug tested if hired, and that employee security is 
a corporate priority. 

4. Deal with bad behavior. Safety directors, 
plant managers, and employers must be acces- 
sible to be effective. Management's prompt re- 
sponse to inappropriate worker behaviors will 
emphasize the importance of safety and har- 
mony in the workplace culture. 



War Games: The Injured 
Worker in an Adversarial 
Health Care System 

Times have changed. Workers can no longer rely 
on local companies to provide lifelong employ- 
ment and eventual retirement within the commu- 
nity. Today's generation of workers are likely to 
face job changes or layoffs. When employees 
find themselves economically cornered and 
threatened, animal instincts for survival may 
resurface. A sense of entitlement or of employer 
wrongdoing may lead to aggressive behavior, 
perhaps stoked by the idea that violence will lead 
to "justice." 

Furthermore, we know that both physical 
and psychosocial issues surround work injuries 



Table 2. Workplace deaths 
In North Caroiina:1992-1993 





1992 


1993 


Traffic accidents 


71 


76 


Assaults/violence 


33 


54 


Equipment/objects 


35 


42 


Falls 


18 


19 


Exposure 


5 


18 


Fires/explosions 


5 


4 


Other 


2 


1 



TOTAL 



169 



214 



Source: NC Department of Labor 



32 



NCMJ / January 1996, Volume 57 Number 1 



whose symptoms last more than three months.''" In such cases, 
the potential for assault or violent behavior may extend into the 
physician's workplace. Without doubt, violent assaults on 
physicians have become more common in recent years (witness 
the attacks on physicians who perform abortions). Angry pa- 
tients and family members have attacked both hospitals and 
health care providers. In 1993,aLos Angeles County physician 
was killed and two other doctors were held hostage by a man 
who stated "I want doctors, not nurses." The assailant held his 
hostages for five hours, telling negotiators that he was in no 
hurry to surrender because he "wanted to let them know how it 
felt to wait [for health care]"." InJune 1994, a gunman entered 
the hospital grounds at Fairchild Air Force Base near Spokane 
spraying bullets. He killed four people and wounded 19, 10 
seriously.'^ 

Illness and injury may lead to serious physical disability, 
prolonged suffering, and even death. Despite knowing this, 
consumers' expectations about medical care have steadily risen 
so that incomplete recovery, medical compUcations, even the 
development of an anticipated medical outcome may lead to an 
aggressive, emotional response by the patient or his or her 
family. In modem America this often takes the form of legal 
redress. Plaintiff lawyers advertise their availability, and many 
advocate an adversarial response. Injured workers who find 
themselves unemployed and without control over their condi- 
tion usually turn to the health care system for help. If the system 
responds slowly, or the injury resolves slowly, those workers 
may seek the advice of attorneys or solicitous family members. 

Ideally, employers should identify injured workers so that 
they may express their concern: "You are valued. We need you. 
Please come back to work as soon as possible." The employer 
should be the first to establish communication, not a solicitous 
relative or local attorney. As the worker recovers, light duty 
should be made available in order to reduce lost productivity 
and the potential that the injured worker will develop a disabil- 
ity lifestyle.'" Management should foster empathy and concern 
toward injured workers, not misunderstanding or ambivalence 
because of the company's losses. When communication from 
the workplace is not forthcoming or maintained, return to work 
is impeded. When workers feel traumatized, emotional factors 
inevitably lead to anger, blame, and variable degrees of conflict. 

Insurance carriers are for-profit businesses. Many adjust- 
ers are medically uneducated, but often assert great control over 
case management The receipt of financial reimbursement and 
other income guaranteed to the injured worker may be delayed 
while mortgage, utility, and car payments pile up. Insurance 
adjusters often ignore the inevitable psychosocial fall-out asso- 
ciated with work injury, preferring to blame the individual or 
identify the problem as pre-existing. 

Lawyers see another side of the truth, seeking payment 
from the dwindling financial resources of the injured worker 
and family at the same time that they seek total and permanent 
disability status for their client The defense attorney wants 
closure and will recommend ways in which the client can save 
money. The injured worker, by this time, wants "justice." 



Physicians are often the source of much conflict Most 
physicians do not know how to manage injured workers or how 
to navigate within the workers' compensation system. Physi- 
cians may see themselves as patient advocates, leading to 
criticism from insurers or employers. On the other hand, phy- 
sicians may choose not to be advocates for the worker but for the 
system. They act as agents of social control, like police in the 
criminal justice system. They speak of "tough love" and be- 
come enforcers instead of healers. 



Profiles of Individuals 
Prone to Violence^'^ 

Psychologists and sociologists stress that the causes of violence 
are multifactorial, but point out that the typical perpetrator of 
violence is a white male between the ages of 30 and 40. 
Individuals involved in work injiuy often have a heavy invest- 
ment in job-related self-esteem, but some have a history of 
oppositional behavior: frequent disputes with management or 
violations of company policy. Violence-prone individuals may 
be emotionally disturbed. They may suffer from extreme stress 
in their personal life or job. They may be loners with minimal 
outside support systems and few interests who tend to external- 
ize blame for disappointments. The workplace may serve as 
their surrogate family. 

When medically evaluating injiu-ed workers, health care 
personnel should be concerned about any individual who ex- 
presses fear of losing outward control (threats of assault or 
homicide) or inward control (suicidal ideation or intent). Clues 
that the patient is looking for help include acts such as doctor 
shopping, gun purchases, reckless driving, or frequent tempera- 
mental outbursts. 

The patient's medical history may reveal episodes of 
altered consciousness or dissociative states leading to violent 
behavior. Caregivers should seek possible organic causes such 
as an underlying brain lesion or previous psychiatric problems 
(Table 1). Past violent acts toward animals, children, or women 
suggest chronically low thresholds for anxiety, anger, and 
frustration, and difficulty controlling aggressive behavior. Pre- 
vious fire-setting, assault, and homicide are important clues, 
especially if the individual has worked within systems where 
violent behavior is frequently encountered, such as the military 
or police. Previous suicide attempts indicate a low threshold of 
impulse control and a proclivity to violence. Early developmen- 
tal history may indicate severe emotional deprivation or rejec- 
tion (such as abandonment by one or both parents), acts of 
sexual or physical abuse, witnessing violence in the home, or 
irresponsible behaviors by parents (such as drug and alcohol 
abuse). Unfortunately, the 1990s have made the graphic depic- 
tion of violence, including murder and sexual assault, generally 
available to children." 

S tress may trigger a desire for vengeance toward those who 
are thought to have damaged a woricer's self-esteem. The 
impulses may be deflected toward the workplace if the injured 



NCMJ / January 1996, Volume 57 Number 1 33 



worker feels humiliated by job termination, particularly after a 
physical injury. Financial collapse and inability to maintain the 
family can invoke animal-like protective instincts. Violence in 
the health care workplace may result from such mechanisms. 



Managing Injured Workers 
at Risk for Violent Behavior 

Case presentation: A38-year-oldman hadworked since age 14 
when he was abandoned by his parents. He was raised by his 
disabled grandmother, and completed a ninth-grade educa- 
tion. He had undergone multiple surgeries as a child, including 
removal of a testicle at age 12. His longest period of employ- 
ment was five years as a squad leader in the military where he 
specialized in demolition. Subsequently, he had a migratory 
work history and had been involved in altercations with several 
of Us supervisors. In 1 991 , after three months of employment in 
a textile mill, he slipped while trying to support a 500-pound 
roll of cloth, twisting and injuring his back. A physician 
prescribed conservative care and relieved him of work duty. 

Six months cfter the injury, he underwent lumbar decom- 
pression at LI -2 andL2-3, but his pain was worse after surgery. 
A recurrent disc herniation was discovered and a surgeon 
offered to operate, but the insurance carrier would not approve 
further surgery until at least six months had passed. The patient 
gained 30 pounds and became deconditioned. He smoked three 
packs of cigarettes and drank three pots of coffee per day. A 
second surgeon was consulted and felt that further surgery was 
not indicated: the patient was cleared for sedentary work. He 
was not able to do this because of perceived worsening of his 
pain. He spent most of his time in bed, adopting a disability 
lifestyle. Twice divorced, he lived alone with two dogs. 

Almost two years after his injury, a psychological evalua- 
tion was approved. Depression was diagnosed, but no treat- 
ment offered. Finally, a spine surgeon performed a kypho- 
reduction with decompression ofLl-2, L2-3, and fusion from 
T9 to L3. Unfortunately, his pain persisted. 

During rehabilitation after surgery, the patient began to 
make angry comments, blaming the operating surgeon. He 
said: "If the lawsuit does not go through, I will end his career 
personally so he can't do this to anyone else." He complained 
about the rehabilitation specialist: "All she does is make 
problems for me. Going to physical therapy is harassment. She 
knows therapy makes me worse and that is why she sends me 
here." He admitted that medical providers incited feelings of 
rage, and he made physical threats against all members of the 
treatment team. He frequently threatened suicide, and on one 
occasion came into the medical office with a gun. He was angry, 
depressed, and could not sleep, but no treatment was pre- 
scribed for these problems. The patient was sent to a multidis- 
ciplinary pain-rehabilitation treatment program but he did not 
follow the discharge recommendations and prescriptions. 

Finally, in 1994, a complete diagnostic reevaluation re- 
vealed that the surgery had been technically in order. The 



patient was tapered off analgesic narcotics and released from 
treatment. He has continued to make violent threats, including 
homicide, toward the doctor, rehabilitation specialist, insur- 
ance carrier, and others. 

This case points out the premorbid biological and psycho- 
logical matrix of an individual at risk for violent behavior. This 
patient endured injury and pain within a "system of care" that 
provided minimal communication and support and responded 
slowly with appropriate medical management Despite eventu- 
ally receiving appropriate care, the patient experienced delays 
in implementation and communication which produced irre- 
versible and permanent consequences, including dissatisfac- 
tion and hostility toward his doctors and care providers. 

Ideally, the treaunent of an injured worker'"* begins at the 
workplace where employers and supervisors offer immediate 
support. Generally patients get frustrated and angry when 
workplace interventions have been absent or ineffective. Dis- 
satisfaction with care and prognostic uncertainty may lead to 
threats of violence toward health care providers. If this occurs, 
the physician should act first to protect himself or herself and 
surrounding staff. Afterward, the patient must be controlled 
using techniques ranging from the support of family members 
to physical restraints and seclusion. 

The appropriate place in which to continue medical care 
will depend on the potential danger and difficulty in securing 
safe communication with the patient. Medical or other media- 
tion experts should be used. A calm, facilitating manner and 
clear, nonjudgmental verbalization by the clinician will often 
establish communication. If the patient's mental capacity or 
judgment are questionable, assistance from security or poUce, 
even hospital admission may be necessary. 

The physician must assess the patient's ability to think and 
talk about his or her problem, so that any distorted perceptions 
and ideas can be identified. Appropriate treatment of depres- 
sion or anxiety are important, as are assessments of organic 
brain dysfunction. Secluding patients who suffer from an acute 
organic cause such as drug intoxication or metabolic enceph- 
alopathy, or those with a potential for self-mutilation is con- 
traindicated. Acute care is summarized in Table 3, below. 
Often the best initial intervention for an acutely disturbed 
patient consists of neiu^oleptic medication (usually thorazine or 



Table 3. Acute care of the violent patient 

1 . Ensure safety of health care personnel. 

2. Establish control and setting for interview. 

3. Summon psychiatrist or mediation expert. 

4. Establish calm nonthreatening environment to 
facilitate patient communication. 

5. Establish differential diagnosis. 

6. Emergency medication management: 
parenteral thorazine or haloperidol; adjunctive 
lorazepam, if needed. 

7. Diagnostic and laboratory evaluation. :..■ 

8. Psychiatry intervention. , ■ 



34 



NCMJ / January 1996, Volume 57 Number 1 



haloperidol) by intramuscular injection. Benzodiazepines or 
barbiturates may provide adjunctive benefit Once psychiatric 
intervention is completed, all parties involved in the injured 
worker's care and case management must come together in 
arbitration. Unfortunately, such vital communication often 
does not occur. 



A Final Word 

Violence pervades modem society. Whether we like it or not, 
the human propensity for aggressive behavior has invaded the 
workplace, the school, and the home. Physicians and other 
health care providers must learn to manage this affliction along 
with other diseases characteristic of modem American society 
and culture. As with all medical disorders, prevention is the 
most cost-effective treatment. However, unlike infectious con- 
ditions vaccination does not seem to be an option. □ 

A uthors' note: This manuscript represents, in part, a synopsis 
of an Industrial Symposium sponsored by Charlotte Orthopedic 
Specialists on December 2, 1994. Speakers included Drs. 
Wheeler and Ruth and The Honorable Harry E. Payne, Jr., 
Commissioner, Department of Labor, State of North Carolina. 
Drs. Wheeler and Ruth thank Joy C. Lewis for helping prepare 
and edit this manuscript. 

References 

1 Tardiff K. Assessment and management of violent patients. Washington, 
DC: American Psychiatric Press, Inc., 1989. 

2 WallStreet Journal. June 15, 1993, A-1. 

3 Stenberg CR, Gammon PJ. Occupational mental health: evolving strate- 
gies for a rapidly changing world. NC Med J 1995;59:228-33. 

4 US Department of Labor, Bureau of Labor Statistics. Census of fatal 
occupational injuries, 1992 and 1993. 

5 Payne HE. Violence and work-related injury: the facts. Industrial Sympo- 
sium: Exploring the Is sues... Defining the Solutions. Charlotte, NC: De- 
cember 2, 1994. 

6 US Department of Labor, Bureau of Labor Statistics. Violence in the 
workplace comes under closer scrutiny. Summary 94-10. August 1994. 

7 Braverman M. Violence: the newest worry on the job. New York Times, 
Decemberl2, 1993, F-11. 

8 Ruth RD. The risk of violence in the healthcare provider system. Industrial 



Symposium: Exploring the Issues. ..Defining the Solutions. Chariotle, 
NC: December 2, 1994. 
9 Polatin PB, Kenny RK, Gatchel RJ, Lillo E, Mayer TI. Psychiatric illness 
in chronic low back pain. The mind and the spine. Which goes first? Spine 
1993;18:66-71. 

10 Wheeler AH. Evolutionary mechanisms on chronic low back pain and 

rationale for treatment. Am J Pain Management 1995;5:62-66. 

1 1 King PH. Who would shoot a doctor? Los Angeles Times, February 10, 

1993, A-3. 

12 New York Times, June 21, 1994, A-10. 

13 Lacayo R, Zoglin R. America's cultural revulsion. Time, June 12, 

1995;145:24-39. 

14 Roth LH, ed. Clinical Treatment of the Violent Person. New York: The 

Guilford Press, 1989. 




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NCMJ / January 1996, Volume 57 Number 1 



35 



Valuing Workers Lessens Back Injury-Related Disability 

Anthony H. Wheeler, MD, Orthopedic Neurologist, Charlotte Spine Center 



A prospective, four-year study of more than 3,000 aircraft 
employees found that job satisfaction and related factors can 
predict back injury claims.' The burden of preventing and 
optimizing treatment of work injuries may not rest with 
doctors but with employers and supervisors. 

Management can enact three types of interventions to 
reduce the risk and impact of work injury.^ 1) They can 
develop structural change whereby poUcies protect the 
worker from injury-prone positions or activities. For the 
most part, such rules and safety regulations have already 
been put in place through OSHA. 2) They can institute 
technological change. Work activities can be ergonomically 
modified to allow their performance with correct body 
mechanics; at-risk activities can be altered or performed by 
robots; improved physical layout of worksites can reduce 
job hazards; workstation redesign may reduce cumulative 
trauma or postures that lead to musculoskeletal injury. 3) 
Lastly, they can increase worker safety and reduce subse- 
quent claims for injury by attitudinal changeP 

The Chelsea Back Program asked managers to undergo 
training to increase awareness of and empathy about em- 
ployee needs. Foremen, supervisors, and upper-level man- 
agers developed a positive stance about dealing with back 
injury claims. Workers and managers were educated about 
the intermittent nature of low back pain and the need for 
immediate treatment Finally, an in-house program allowed 
workers to be treated at the worksite while continuing to 
work. Workers were educated during these treatment ses- 
sions and light-duty work was made available. The results 
were dramatic. The average number of claim cases dropped 
53%; theaverage number of days lost to injury dropped 54%. 
Compensation costs per claim fell by 76% and medical costs 
by 68%. The average total cost per claim was reduced by 
75%." 

Another study performed in a Canadian geriatric hospi- 
tal used a two-stage intervention to demonstrate similar 
successful outcome." A personnel program improved com- 
munication between claimant, doctor, workers' compensa- 
tion board (WCB), and hospital. When notified of back 
injury, program staff immediately contacted both the claim- 



ant and the WCB, and made follow-up phone calls every 10 
days to insure that the claim progressed smoothly through 
proper channels. Workers with extended claims were exam- 
ined for retraining into permanent light-duty jobs. The WCB 
contacted management when light-duty jobs were needed 
for return to work. Finally, communications about return to 
work were documented and filed. There was a decrease in 
the length of claims and a drop in the frequency of reported 
claims, possibly because of procedural improvements and 
possibly because the staff realized that new claims were 
being carefully documented and recorded. Some marginal 
claims that may have resulted in wage loss were not reported, 
but another factor may well have had a valuable effect on the 
number and length of claims filed: the hospital had made a 
statement about how it valued each injured worker. In effect, 
it said: "As a worker, you are our most valued resource, and 
we cannot afford to replace you." Injured staff members 
were not ignored. They were immediately phoned and told 
how important they were, how much the hospital needed 
them, and to return to work as soon as possible.* 

The same hospital system implemented a second pro- 
gram consisting of individual and small-group back care 
education by a physical therapist." A letter introduced the 
back program as an answer to the high injury rate and a 
second, personal letter from the physiotherapist was sent to 
each nursing staff member. This may have had a positive 
psychological effect since the program was seen as being 
implemented by management for the benefit of employees 
who, therefore, felt a sense of self- value. The high injury rate 
was viewed as an organizational problem needing an orga- 
nizational solution. 

Individual employee interventions have usually been 
disappointing, but when upper management is involved, 
these programs become the system norm, and are culturally 
imprinted. Staff members recognize that management is 
financing a highly visible program for their benefit, and 
these organizational changes become long-lasting. In sum- 
mary, attitudinal intervention that involves upper manage- 
ment makes the individual worker feel valued and may have 
the largest impact on injury claims and disability. □ 



References 

1 Bigos SG, Battie MC, Spenger DM, etal. A prospective study of 
work perceptions and psychological factors affecting the report 
of back injury. Spine 1991:16;l-6. 

2 Fitzler SL, Berger RA. Attitudinal change: the Chelsea Back 
Program. Occup Health & Safety 1982:52;24-6. 



Fitzler SL, Berger RA. Chelsea Back Program: one year later. 
Occup Health & Safety 1983:52;52-4. 

Wood DJ. Design and evaluation of a back injury prevention 
program within a geriatric hospital. Spine 1987: 12; 77-82. 



36 



NCM J / January 1996, Volume 57 Number 1 



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38 NCMJ / January 1996, Volume 57 Number 1 



Duke University Medical Center 

Continuing Medical Education Course 

April 13, 1996: 

Hepatobiliary and Liver Transpiant Update 



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CME Calendar 



February 1-2 (and September 4-6) 
ACLS Retraining Course 

Place: Rex Healthcare, 4420 Lake Boone Trail, Raleigh 
Credit 8 hours, American Academy of Family Physicians 
Fee: $75 
Info: Iris Ahlheit, RN, Course Coordinator, Rex Healthcare, 

4420 Lake Boone Trail, Raleigh 27607, 

919/783-3161 

February 7-10 

International Conference on Physician Health 

Uncertain Times: Preventing Illness, Promoting Wellness 

Place: Sheraton San Marcos, Chandler, AZ 
Credit up to 23 hours Category 1 , AMA 
Info: Elaine Tejcek, 312/464-5073, 800/621-8335, or 
fax: 312/464-5841 

February 8-9 

Update: Research and Treatment of Sex Offenders 

Place: Howard Johnson Plaza Hotel, Fayettcville 

Fee: $140; partial attendance fees available 

Info: Dennis Goodwin, Cumberland Hospital of Cape Fear 

Valley Medical Center, 3425 Melrose Road, 

Fayetteville 28304, 800/659-5546 

February 9, 16, 23, and March 1 
Epidemiology and Prevention of 
Vaccine-Preventable Diseases 

Place: Public Health Training Network videoconference sites 

Credit 14 hours Category 1 , AMA 

Info: Pam Reese, UNC School of Public Health, 919/ 

966-1 104, e-mail: immunization@ sophia.sph. unc.edu 

February 14-16 

Advancing Substance Abuse Treatment — Applying 

Current Research: A Tri-State Regional Conference 

Place: Holiday Inn Four Seasons, Greensboro 
Credit 10.5 hours Category 1, AMA 
Info: Governor's Institute on Alcohol and Substance Abuse, 
919/990-9559 

February 19 

7th Annual Triangle Update in Cardiology 

Place: Marriott Crabtree, Raleigh 

Credit: prescribed AAFP credits applied for 

Info: Maggie Clay, American Heart Association, 

NC Affiliate, Inc., Region 5, 3901 Computer Drive, 
Suite 1 10, Raleigh 27609, 919/783-7853 



February 29-March 1 (and May 30-31, 
October 31 -November 1) 
ACLS Provider Course 

Place: Rex Healthcare, 4420 Lake Boone Trail, Raleigh 

Credit 13.75 hours AAFP 

Fee: $150 

Info: Iris Ahlheit, RN, Course Coordinator, Rex Healthcare, 

4420 Lake Boone Trail, Raleigh 27607, 

919/783-3161 

March 1-3 

3rd Annual Pinehurst Medical Symposium 

Place: Pinehurst Resort and Country Club, Pinehurst 

Credit 7 hours Category 1 , AMA 

Fee: $50-$540 (call or write for details) 

Info: Suzanne Riley, Moore Regional Hospital, 

Educational Services,P.O.Box3000,Pinehurst28374, 

910/215-1585 

March 2-3 

Violence: Implications for Clinical Practice 

Place: Royal Sonesta Hotel, New Orleans, LA 

Credit 14 hours Category 1, AMA 

Fee: call for info 

Info: Maria Gorrick, American Psychiatric 

AssociaUon, 202/682-6145, fax: 202/682-6102, 

e-mail: mgorrick@psych.org 

March 14-17 

North Carolina Medical Society Spring Conference 

Place: Washington Duke Inn & Golf Club, Durham 
Info: Alan Skipper, NCMS, 800/722-1350 (in NC), 
or 919/833-3836 

March 15-16 

Neurology for the Primary Care Provider 

Place: Winston-Salem 
Credit 1 1 hours Category 1 , AMA 
Info: Division of CME, Bowman Gray School of Medicine, 
910/7164450 or 800/277-7654 

March 16 

Innovations in Diabetes Management for Primary Care 

Place: Sarah W. Stedman Center for 

Nutritional Studies, Durham 
Info: Duke Office of CME, 800/222-9984 or 

919/684-6485 

Continued on page 46 



40 



NCMJ / January 1996, Volume 57 Number 1 



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MODERN MEDICINE 



Sclerotherapy of Telangiectases 
Using Sodium Tetradecyl Sulfate 
(Sotradecol) 

Catherine Hren, MD, Carlos Garcia, MD, and Robert E. Clark, MD, PhD 



Telangiectases are dilated blood vessels 
which measure 0. 1 mm- 1 .0 mm in diam- 
eter. They are also known as "broken 
veins" or "spider veins" (Figures 1, 2, 
page 44). They occur mainly in women, 
mainly on the face and lower extremities, 
and represent an expansion of an arteri- 
ole, capillary, or venule. The causes of 
telangiectases are many, but they are 
thought to share a common mechanism: 
the release or activation of vasoactive 
substances by conditions such as anoxia, 
hormone stimulation (steroids, estrogens), 
or exposure tochemicals, infection, physi- 
cal trauma, radiation, or sun. 

The prevalence of telangiectases is 
difficult to estimate. Various authors sug- 
gest that they are found in between 20% 
to 50% of American women.' Telan- 
giectases are a frequent reason for con- 
sultation with dermatologists because they 
are unsightly and a cosmetic concern for 
patients. Also, at least 50% of patients 
with telangiectases complain of pain, tired 
legs, pruritus, burning, stinging, cramps, 



Dr. Hren is a third-year resident in Derma- 
tology, Dr. Garcia is a senior fellow in 
Dermatologic Surgery, and Dr. Clark is 
Director, Dermatobgic Surgery, Box3915, 
Duke University Medical Center, Durham 
27710. 



or edema. It is important that dermatolo- 
gists and general practitioners be aware 
of what treatments are available. 

Telangiectases can be treated in sev- 
eral ways (Table 1, at right). Electro- 
surgery and dermabrasion are effective, 
but carry a significant risk of scarring. 
Treatment with the vascular tunable dye 
laser is effective in only 50% of the cases, 
and telangiectases of the legs are espe- 
cially resistant, probably because they 
are different from and less sensitive than 
telangiectases of the face. Therefore, 
sclerotherapy is currently the treatment 
of choice for leg telangiectases. 

Sclerotherapy has been performed 
successfully in EuroJX^ for decades, but it 
has only become popular in the United 
States during the past 10 to 20 years. In 
this paper we will discuss treaunentof leg 
telangiectases with sodium tetradecyl 
sulfate (sotradecol, Elkins-Sinn Inc., 
Cherry Hill, NJ ). We review and summa- 
rize the indications, technique, therapeu- 
tic results, and possible complications of 
sclerotherapy. 



Definition 

Sclerotherapy refers to the injection of a 
foreign substance into the lumen of a 
vessel to cause thrombosis and subse- 
quent fibrosis. Two mechanisms of ac- 
tion are proposed: 1) activation of throm- 



Table 1 . Treatments available for 
telangiectases 

Electrosurgery 

Dermabrasion 

Vasculartunable dye laser ablation 

Sclerotherapy 



boplastin, which in turn activates the ex- 
trinsic pathway of blood coagulation; 2) 
direct endothelial damage, exposing 
subendothelial collagen and leading to 
platelet adherence and aggregation, 
thereby activating the intrinsic pathway 
of blood coagulation.^ Both lead to oblit- 
eration of the telangiectatic vessel. 

Sotradecol, one of two sclerosants 
approved by the Food and Drug Admin- 
istration for treating telangiectases and 
varicose veins, was first described in 1946 
and became popular in the 1960s. It is a 
long-chain fatty acid salt of an alkali 
metal; it has both hydrophobic and hy- 
drophilic regions. When injected into 
blood vessels, the hydrophobic portion 
partitions into the lipid membrane of en- 
dothelial cells, reducing surface tension 
with the surtounding aqueous environ- 
ment. Maceration of the endothelium 
occiu^s within seconds and intimal dam- 
age follows shortly thereafter. The extent 
of endothelial damage (and, therefore, 
the relative efficacy) can be modified by 
varying the concentration of the solution. 



42 



NCM J / January 1996, Volume 57 Number 1 



Technique 

Sclerotherapy is an outpatient procedure. 
Patient evaluation should incl ude a medi - 
cal history and a physical examination. 
Contraindications to sclerotherapy in- 
clude pregnancy, diabetes, and allergy to 
the sclerosant (Table 2, below). Patients 
with a history of thrombophlebitis, deep 
venous thrombosis, or peripheral vascu- 
lar disease should be evaluated by ultra- 
sound before sclerosing the sujjerficial 
varicose veins, which may represent the 
only patent outflow veins in the legs.' 
Those who are bedridden are poor candi- 
dates because patients must walk to 
achieve good results. Also, emotionally 
unstable patients should be evaluated 
carefully since they may constitute a po- 
tential source of Utigation in case of com- 
plications. Patients with simple telangiec- 
tases and no associated varices may be 
treated with sclerotherapy without fur- 
ther evaluation. 

Informed consent should be obtained 
and the lesions photographed before treat- 



Table 2. Contraindications to 
sclerotherapy 

Pregnancy 
Diabetes mellitus 
Allergy to sclerosant agent 
History of thrombophlebitis 
History of deep venous thrombosis 
Severe peripheral vascular disease 
Bedridden patients 
Emotionally unstable patients 



Table 3. Complications of sclero- 
therapy 

A. Minor adverse effects 

Pain on injection 
Urticarial reaction 
Edema 

B. Major complications 

Necrosis (3%) 
Pigmentation (30%) 
Malting (15%) 
Thrombosis (<0.1%) 
Thrombophlebitis (0.5%) 
Pulmonary embolism (rare) 
Arterial injection (rare) 
Anaphylactic reaction (rare) 



ment. Skin preparation consists of rub- 
bing for 10 seconds with an alcohol pad. 
This both disinfects the skin and changes 
its optic properties so that vessels can be 
better seen. Injection is made with a dis- 
posable 3-cc syringe and a 30-gauge 
needle. With the patient supine, the op- 
erator rests the injecting hand on the leg 
of the patient, holding the syringe parallel 
to the skin with the needle bevel up. The 
free hand is used to stretch the skin ahead 
of the needle. The needle is introduced 
into the vessel ata 30° inclination (Figure 
3a, nextpage). With experience one leams 
to feel the needle enter the vessel. The 
technique requires that the needle be 
slowly advanced 1 mm-2 mm, entering 
the vein just enough to allow infusion of 
solution with minimal pressure on the 
plunger. Intraluminal injection is con- 
firmed when the vessel is seen to clear 1 
mm-3 mm in front of the needle tip (Fig- 
ure 3b, next page). The injection must 
proceed very slowly. The sclerosing so- 
lution should produce clearing 1 cm-2 cm 
in diameter around the point of injection, 
and the total amount injected should not 
exceed 0.5 cc at a single site. As a rule, the 
vein must be kept filled with sclerosant 
for five to 10 seconds using minimal 
injection pressure. 

Sclerotherapy of large telangiectases 
should be performed first. These vessels 
may act as "feeders" of smaller telangiec- 
tases, and their injection frequently pro- 
duces clearing of both. If an intradermal 
wheal is produced, the injection should 
be stopped and the area massaged be- 
cause extravasated sclerosant can pro- 
duce tissue necrosis. 

Successfully treated areas should be 
immediately compressed with cotton balls 
and paper tape for 20 seconds to improve 
results. After injection, a compression 
bandage should be worn for 24 hours to 
increase contact between the sclerosing 
agent and the vessel wall and (in theory) 
to decrease formation of thrombus and 
the incidence of pigmentation and mat- 
ting.^^ The use of compression bandages 
and stockings remains controversial — 
some authors reportexcellent results with- 
out compression . Walking after treatment 
is recommended to decrease the risk of 
thrombosis and other complications. 



At the first session only one or two 
"test areas" are treated, to allow patients 
to evaluate results and to detect allergies 
to the solution. Patients are seen in fol- 
low-up after four to six weeks, the time 
needed for treated areas to fade maxi- 
mally, and a decision is made about fur- 
ther therapy. The maximum recom- 
mended amount of sotradecol used per 
session should not exceed 10 cc of a 1% 
solution or 15 cc of the usual 0.3% (di- 
lute) solution. 



Results 

At the first sclerotherapy session several 
proximal veins are treated. If the treat- 
ment is successful, in four to six weeks 
the treated vessels and several more do wn- 
stream will have faded (Figures 4a, 4b, 
next page). If there is no clearing, the 
same or (as we prefer) an increased con- 
centration of sclerosant can used for a 
second treatment 

In a review of 200 charts, Puissegur 
Lupo' reported that telangiectases cleared 
in 95% of cases and that 98% of patients 
were satisfied; those dissatisfied were 
treatment failures. Puissegitf Lupo did 
not use sou-adecol in his series, but a 
review of 20 years experience with 
sotradecol' found that 80% to 90% of 
telangiectases cleared. The treated areas 
did not recur, and even after therapy was 
completed, 5% of the patients continued 
to have further clearing. Complications 
of treatment included ulceration, pigmen- 
tation, and matting. 

Treatment fails in about 7% of the 
patients. Failure (or incomplete clearing) 
has been associated with concurrent use 
of oral contraceptives, and female pa- 
tients should be properly advised about 
this. If clearing is incomplete or new 
telangiectases appear at the treatment sites 
even after re-treatment, sclerotherapy 
should be stopped and other treatments 
considered. 



Complications 

Table 3, at left, lists the complications of 
treatment. Minor adverse effects include 



NCMJ / January 1996. Volume 57 Number 1 



43 



pain on injection, 
urticarial reactions, 
and edema. Injection 
of sotradecol is almost 
always painful, but 
the pain is usually 
mild to moderate and 
most patients tolerate 
the procedure without 
anesthesia. Pain on 
injection can be de- 
creased by using a 
sharp 30-gauge 
needle and by dilut- 
ing the sclerosant with 
normal saline. Local- 
ized urticaria and 
pruritus that resolve 
within an hour do not 
represent an allergic 
reaction (Figure 5, 
next page). Systemic 
allergic reactions are 
rare and consist of 
generalized urticarial 
reactions (which usu- 
ally respond to oral 
antihistamines) and 
anaphylaxis (which 
should be treated with 
epinephrine). Finally, 
edema may be seen if 
large amounts (more 
than 1 cc) of sotra- 
decol are injected near 
the ankles; small 
amounts should be 
used. 

Skin necrosis is 
one of the most seri- 
ous complications of 
sclerotherapy (Figure 
6,nextpage).Therisk 
of necrosis is in- 
creased by use of sotradecol concentra- 
tions greater than 1%, extravasation of 
sclerosant, injection into a dermal arteri- 
ole feeding a telangiectasis, reactive va- 
sospasm, or excessive cutaneous pres- 
sure created by incorrect compression. 

Tretbar* reported an ulceration rate 
of 60%-70% after use of a 1% solution; 
the rate dropped to 3% when 0.3% solu- 
tion was injected, and the ulcers were 
smaller, less painful, and healed more 




■ 


■ 


^^H 


^^^1^ 35 1 eo 



Fig 1 (left): Telangiectatic vessels on the thigh, a very common location. Fig 2 (right): Close-up view of 
so-called "spider veins." 



^^^^^^^^0^^^ 




/ y 


' > 




^ 




Fig 3a (left): Injection of sclerosant solution using a 3-cc syringe with a 30-gauge needle held at 
approximately 30° inclination. Fig 3b (right): Partial clearing of vessels during injection confirms 
intraluminal deposition of sotradecol. 




Fig 4a (left): Clinical appearance of telangiectases of the lateral thigh before sclerotherapy. Fig 4b (right): 

Almost complete disappearance of vessels six weeks after sclerotherapy. 



quickly without scairing. Ulceration can 
occur even without extravasation, but in 
the event of extravasation, Goldman' rec- 
ommends injection of hyaluronidase 
(Wydase, Wyeth-Ayerst Laboratories, 
Philadelphia, PA) to induce accelerated 
dilution of sclerosant in tissues, cellular 
stabilization, and promote wound repair. 
Should ulceration occur, surgical exci- 
sion and closure should be attempted as 
early as possible in order to achieve the 



best cosmetic outcome. Otherwise, the 
ulcer should be wrapped with an occlu- 
sive dressing to speed healing and to 
decrease pain. Most ulcers heal in ap- 
proximately four to six weeks. 

Increased pigmentation along the 
course of treated vessels occurs up to 
80% of patients injected with 1% 
sotradecol solution; with 0.3% solution, 
the incidence is 30% (Figure 7, next page). 
The etiology of hyperpigmentation is 



44 



NCMJ / Januarj 1996, Volume 57 Number 1 



unclear but seems to involve both post- 
inflammatory incontinence of melanin 
and hemosiderin deposition.' Ackerman 
postulated that after sclerotherapy, red 
blood cells deposit hemoglobin in the 
dermis leading to iron accumulation and 
the formation of free-radicals which 
stimulate melanogenesis. The similar 
findings of extravasated red blood cells 
and pigment incontinence in venous sta- 
sis dermatitis lend support to this theory. 
Risk factors for increased pigmentation 
include dark skin, increased serum fer- 
ritin levels, increased perimenstrual cap- 
illary fragility, formation of thrombi after 
sclerotherapy, use of sclerosant concen- 
trations higher than 0.5%, increased in- 
travascular pressure, and use of mino- 
cycUne. To prevent hyperpigmentation, 
experts recommend using appropriate 
concentration of sclerosant for different 
sized vessels, avoiding excessive syringe 
pressure, and using proper compression 
after therapy. Patients should avoid tak- 



ing minocycline. Should thrombi develop 
they must be evacuated early.' 

Treatment of pigmentation is disap- 
pointing. Exfoliants such as trichloroace- 
tic acid, cryotherapy , retinoic acid, chelat- 
ing agents, and laser ablation have been 
minimally effective. Time may be the 
best therapy since most hyperpigmenta- 
tion resolves within 24 months, although 
in approximately 5% of patients it is 
permanent. Cosmetics such as Derma- 
blend can camouflage the pigmentation. 

Matting refers to the appearance of 
new, fine telangiectases adjacent to treated 
areas (Figure 8, below). These vessels are 
less than 0.2 mm in diameter and occur in 
15% to 24% of patients, usually women. 
They represent either newly formed ves- 
sels or dilatation of existing vessels once 
the larger ones are occluded.' Risk fac- 
tors for matting include obesity, estrogen 
treatment, high-injection pressure, high 
concentration of sotradecol, pregnancy, 
and a family history of telangiectases. 




Fig 5 (left): Urticarial reaction immediately following sclerotherapy. This does not represent an allergic 
reaction. Fig 6 (right): Small area of ulceration and necrosis caused by extravasation of sotradecol. 
Conservative wound care should lead to complete healing in four to six weeks. 




Fig 7 (left): Areas of brown pigmentation after sclerotherapy with sotradecol. This transient complication 
is seen in approximately 30% of patients. Treatment is disappointing. Fig 8 (right): Telangiectatic matting 
occurring two months after sclerotherapy. This can be treated with further sclerotherapy or vascular 
tunable dye laser ablation. 



Matting resolves in approximately 80% 
of cases after three to 12 months, but is 
permanent in 10% to 20% of cases. To 
prevent matting one should use a 30- 
gauge needle, a low-injection pressure, 
and inject only enough sclerosant to pro- 
duceblanching 1 cm-2cm from the injec- 
tion site.The vascular tunable dye laser 
may be used to treat matting, and 
Puissegur Lupo recommends topical ap- 
plication of diprolene ointment to injec- 
tion sites to decreasing its incidence. 

Thrombi may appear after therapy as 
palpable, dark blue, linear swellings along 
the course of the vessels. There is often 
no pain or erythema to indicate phlebitis. 
Evacuation of the clot by incising the 
vessel and expressing the contents speeds 
healing and decreases the risk of pigmen- 
tation . The incised vessels should be com- 
pressed for several days after extraction 
of the clou True thrombophlebitis is seen 
in 0.1% to 1% of patients and should be 
treated with compression, leg elevation, 
and pain medication. 
The incidence of 
pulmonary embolism 
following sclero- 
therapy is extremely 
rare (less than 0. 1 %) 
and probably repre- 
sents an extension of 
a superficial throm- 
bus into the deep ve- 
nous system. Oral 
contraceptives may 
increase this risk. 
Compression, ambul- 
ation after treatment, 
and the use of small 
quantities (0.5 cc) of 
sclerosant per injec- 
tion site minimize the 
risk of embolization. 
Inadvertent arte- 
rial injection of scler- 
osant is rare but a Uiie 
emergency. Intense 
pain, blanching of the 
siuTounding skin, and 
cyanosis over a large 
area require antico- 
agulant therapy and 
consultation with a 
vascular surgeon. 



NCMJ / January 1996, Volume 57 Number 1 



45 



Conclusions 

Sclerotherapy of leg telangiectases, with 
a success rate of 93% and excellent pa- 
tient satisfaction, is an increasingly popu- 



lar procedure. The results of therapy are 
predictable and reproducible. Dermatolo- 
gists should be prepared to offer this 
simple and cosmetically acceptable alter- 
native to surgery. Sotradecol is a versatile 



agent and complications can be kept to a 
minimum by proper selection of patients, 
proper technique, and use of appropriate 
concentrations of sclerosantsolution. □ 



References 

1 Weiss RA, Weiss MA. Sclerotherapy. In; 
Wheeland RG. Cutaneous Surgery. WB 
Saunders Co., 1994:951-81. 

2 Goldman MP. Sclerotherapy treatment for 
varicose and telangiectatic leg veins. In: 
Coleman WP, Hanke CW, Alt TH, Asken 
S. Cosmetic Surgery of the Skin. Philadel- 
phia: BC Decker, 1991:197-211. 

3 Fronek HS. Non-invasive examination of 
the venous system in the leg: pre-sclero- 



therapy evaluation. J Dermatol Surg Oncol 
1989;15:170-3. 

Goldman MP, Bennett RG. Treatment of 
telangiectasia: a review. J Am Acad 
Dermatol 1987;15:167-82. 
Puissegur Lupo ML. Sclerotherapy: review 
of results and complications in 266 pa- 
tients. J Dermatol Surg Oncol 1989; 15:2 10- 
9. 
Tretbar LL. Injection sclerotherapy for spi- 



der telangiectases: a 20-year experience 
with sodium tetradecyl sulfate. J Dermatol 
Surg Oncol 1989;15:223-5. 

7 Goldman MP, SadickNS, Weiss R A. Cuta- 
neous necrosis, telangiectatic matting and 
hyperpigmentation following sclerother- 
apy. Dermatol Surg 1995;21:19-29. 

8 DeGrootWP. Treatment of varicose veins: 
modem concepts and methods. J Dermatol 
Surg Oncol 1989;15:191-8. 



Continuing Medical Education 

continued from page 40 



March 20-23 

20th Annual Internal Medicine Conference 

Place: Friday Center, UNC-Chapel Hill 

Credit: approx. 24 hours Category 1, AM A 

Fee: $400 

Info: Registrar, UNC Office of CME, CB# 7000, 23 1 
MacNider Hall, UNC School of Medicine, Chapel 
Hill 27599-7000,919/962-2118, fax: 919/962-1664 

March 22-23 

9th Annual Surgical Symposium and Harrill Lecture 

Place: Winston-Salem 
Credit: 9 hours Category 1 , AM A 

Info: Division of CME, Bowman Gray School of Medicine, 
910/716-4450 or 800/277-7654 

March 25-28 

Alton D. Brashear Postgraduate 

Course in Head and Neck Anatomy 

Place: Medical College of Virginia, Richmond, VA 

Credit: 44 hours Category 1 , AMA 

Info: Dr. Hugo R. Seibel, Department of Anatomy, 

P.O. Box 980709, Medical College of Virginia, 

Richmond, VA 23298-0709 

April 1-2 

20th Annual Symposium of the 

UNC Lineberger Comprehensive Cancer Center: 

New Insights into the Genetic Basis of Cancer 

Place: Friday Center, UNC-Chapel Hill 
Info: Sara Rimmer, 919/966-3036 



AprU 10-12 

Current Concepts of Clinical Infectious Disease 

Place: Boar's Head Inn, Charlottesville, VA 
Credit: 17 hours Category 1, AMA 
Fee: $455 (if before March 13) 
Info: University of Virginia, Office of CME, Box 368, 
Health Sciences Center, Charlottesville, VA 22908 

April 13 

Hepatobiliary and Liver Transplant Update 

Place: Durham 

Credit 8 hours Category 1 , AMA 
Info: Duke Office of CME, 800/222-9984 or 
919/684-6485 (see ad on page 39) 

April 26-27 
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Place: Winston-Salem 

Credit 9 hours Category 1 , AMA 

Info: Division of CME, Bowman Gray School of Medicine, 

910/7164450 or Physician Access Line, 

800/277-7654 

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Carolinas Medical Center Symposium 

Place: Charlotte Convention Center 

Credit: up to 24 hours Category 1 , AMA 

Fee: call for info 

Info: Mary Anne Cox, CME Coordinator, CMHA Office of 

CME, 1366 E. Morehead St, Charlotte, NC 28204, 

704/355-8631 or 800/562-7314 



46 



NCMJ / January 1996. Volume 57 Number 1 



SCREENING FOR DISEASE 



Prostate Cancer Screening Update 

Should New Developments Change Our Practice? 

Jeffrey G. Wong, I^D 



Two years ago in the Journal,^ Feussner 
and I looked at screening for prostate 
cancer. We began with the scenario of a 
primary care generalist physician caring 
for a 63-year-old man who, while in ex- 
cellent health, had mild symptoms of 
prostatism. On physical examination, 
there was some prostatic enlargement but 
no other abnormal findings, and the ques- 
tion was whether (and how) to screen him 
for prostate cancer. 

We determined that die natural his- 
tory of prostate cancer was not well known 
and that the blood level of prostate spe- 
cific antigen (PSA) was a poor predictor 
of prostate cancer. We concluded that 
there was little evidence to justify screen- 
ing the patient for prostate cancer. In the 
two years since we wrote, further reports 
on the utility of prostate cancer screening 
have appeared. Michael Milken, the fa- 
mous stock-market criminal, has been 
touting the fact that his prostate cancer 
was discovered only because he insisted 
(in his mid-40s) that a PSA be done; he is 
urging other men to be tested. Since 
screening for prostate cancer by primary 
care practitioners and urologists has be- 
come increasingly common, re-visiting 
the issue seems justified. Once again, I 
will use our six guidelines to decide 
whether and how to screen asymptomatic 
patients for disease.^ 



Target Disease 
Considerations 

Is the disease common or serious enough 
to warrant screening? 

Yes. Prostate cancer continues to be an 
important health issue. It is now the most 
common cancer in men and the third- 
leading cause of cancer death in Ameri- 
can men. It is estimated that, in 1995, 
there will be 244,000 new cases of pros- 
tate cancer and 40,400 deaths due to this 
disease.' In 1 993 when our original paper 
was published, there were 165,000 new 
cases of prostate cancer and 65,000 
deaths." The number of cases of prostate 
cancer is rapidly increasing, but the num- 
ber of patients dying from the disease 
year is actually diminishing! 

Prostate cancer is largely a disease of 
older men; 80% of all cases occur in 
patients over the age of 64 and more than 
half of the deaths occur in men over 74 
years old." The estimated hfetime prob- 
ability that a man will be diagnosed with 
prostate cancer is 9%, and the cumulative 
risk of dying from prostate cancer is 3%.' 
The recent increase in numbers of pa- 
tients diagnosed with prostatecancermay 
represent the effect of mass screening for 
this disease rather than an actual increase 
in the incidence of this disease. 

Is there a pre-symptomatic phase in the 



natural history of the disease during 
which time a test can detect it? 

Yes. Epidemiological studies support the 
premise that prostate cancer develops 
locally within the substance of the pros- 
tate gland.' The palpation of prostatic 
nodules during digital rectal examination 
of asymptomatic patients can lead to the 
discovery of prostate cancer, and studies 
of patients undergoing transurethral re- 
section of the prostate (TURP) for non- 
specific urinary symptoms (hesitancy, 
frequency, urgency, retention) may re- 
veal previously undetected, localized can- 
cer in the surgically removed tissue chips.' 
But it is surely also accurate to say that 
prostate cancer produces no specific 
symptoms that can distinguish it from 
benign prostatic conditions. 

Are there effective treatments for the 
disease available to use after early de- 
tection? 

We still don't know! Patients diagnosed 
with localized prostate cancer have im- 
proved survival rates: The 10-year, dis- 
ease-free survival rate of patients with 
stage A prostate cancer is around 87%; 
with stage Bl disease, 61%; and with 
stage C disease, 35%.' The median sur- 
vival of patients with stage D is 10-30 
months depending on the degree and ex- 
tent of metastatic spread.' 

The natural history of prostate can- 



Dr. Wong is Assistant Professor, Division of General Internal Medicine, Box 3375, Duke University Medical Center, Durham 2771 0. 



NCMJ / January 1996, Volume 57 Number 1 



47 



cer is poorly understood and it is not clear 
whether the better survival of patients 
with "early-stage disease" is due to effec- 
tive treatment, or because of the con- 
founding influences of lead-time and 
length time biases (for a discussion, see 
NC Med/ 1993;54:438-40). Forinstance, 
it may be that "limited-stage prostate 
cancer" is less virulent than metastatic 
prostate cancer (and that is why it is still 
at a limited stage when found). Support 
for this notion comes from that fact that 
only about one of every 380 men with 
histological evidence of prostate cancer 
actually dies of the disease.'" Further- 
more, as already noted, the number of 
men diagnosed with prostate cancer is 
increasing, but the number dying of the 
disease is decreasing. 



"Some recent 

data suggest that 

untreated, localized 

prostate cancer has a 

survival rate equivalent 

to that of treated, 

localized disease." 



Mortality from intercurrent disease 
may be more significant than that due to 
prostate cancer. Several case series and 
one cohort study have investigated this 
issue. Epstein and colleagues at Johns 
Hopkins followed a group of 94 men 
(mean age of 75) with limited-stage pros- 
tate cancer discovered incidentally dur- 
ing TURP.' No further treatment was 
systematically given to the group. Only 
eight men had clinical progression of the 
disease (six of them died of prostate can- 
cer); 26 men died of other causes within 
four years of diagnosis, and 60 men had 
no evidence of progression of their dis- 
ease. 

Some recent data suggest that un- 
treated, localized prostate cancer has a 
survival rate equivalent to that of treated, 
localized disease. Johansson et al" fol- 
lowed 223 patients with early-stage pros- 
tate cancer who did not undergo pros- 



tatectomy. The patients were given hor- 
monal therapy if they later became symp- 
tomatic. Only 19 of the 223 patients sub- 
sequently died of prostate cancer; 105 
patients died from other causes. The 10- 
year survival rate for untreated localized 
prostate cancer patients was 87%. A sub- 
group of patients who underwent radical 
prostatectomy for limited-stage prostate 
cancer had essentially the same 10-year 
survival rate. To be clear, however, it has 
been shown that patients with high-grade 
lesions do not do fare well with expectant 
therapy alone.'^ 

Predicting the metastatic potential 
of prostate cancer is complicated. Spe- 
cific markers on cancer cells have been 
suggested as predictors," but their clini- 
cal utility is minimal at present. Some 
authors have proposed to distinguish cl i ni- 
cally significant from insignificant oc- 
cultpros tale cancer using estimates of the 
volume and physical location of the ori- 
gin of the tumor, the grade of tumor 
differentiation, its growth pattern and 
chromosomal status, and whether or not 
the PSA test was abnormal.'" These mod- 
els represent intriguing hypotheses but 
have never been studied in a prospective 
trial. 

The prevalence of occult prostate 
cancer is extremely high, quite possibly 
higher than seen in any other organ in the 
body.'^ Autopsy data indicate that by age 
80, "cancer" can be demonstrated in 60%- 
70% of prostates exam ined. " Recent stud- 
ies of prostate specimens incidentally 
removed during surgery for bladder can- 
cer found similarly high rates of preva- 
lence.'^ The perplexing question concerns 
deciding in which patients the presence 
of prostate cancer will really make a 
difference in terms of longevity or qual- 
ity of life. A 50-year-old man has roughly 
a 40% chance of developing prostate can- 
cer during his Hfetime, but only a 2%-3% 
chance of dying from it.' 

Several trials in progress may even- 
tually provide us with information about 
whether early detection and subsequent 
treatment of prostate cancer saves 
lives. "^° Unfortunately, it will be years 
before these studies have enrolled enough 
padents and followed them long enough 



to detect with statistical reliability any 
differences caused by the screening or 
the treatment. 



Screening Test 
Considerations 

Are there screening tests with accept- 
able sensitivity and specificity available 
to detect the target disease? 

The answer is still NO. In our previous 
discussion, we noted that digital rectal 
examination (DRE), transrectal ultra- 
sound study (TRUS), and PSA blood 
tests were available to cUnicians. These 
three continue to be used, but still have 
not been shown to be of practical benefit 
in prostate cancer screening. The PSA 
has been investigated by itself,^' and in 
the variations described below. Unfortu- 
nately, none has proven to be of signifi- 
cant practical utiUty . 



"The perplexing 

question concerns 

deciding in which 

patients the presence 

of prostate cancer will 

really make a difference 

in terms of longevity 

or quality of life." 



The "PSA density" (PS AD) seeks to 
surmount the obstacle posed by the fact 
that benign prostatic hypertrophy (BPH) 
causes the PSA to rise. By using TRUS, 
the volume of the prostate gland is esti- 
mated and a ratio between this volume 
and the serum PSA calculated. Initial 
reports claimed that the PSAD was a 
more sensitive test for prostate cancer 
than PSA alone, but the false-positive 
rate was not greatly improved." The 
PSAD may help differentiate BPH from 
prostate cancer when PSA values are in 
the 4.0-10.0 ng/mL range,^' but its use- 
fulness as a screening test remains in 
question." 



48 



NCMJ / January 1996, Volume 57 Number 1 



Since PSA values (and prostate vol- 
umes) directly correlate with the age of 
the patient, age-specific PSA reference 
ranges have been proposed." The effect 
of using different threshold norms de- 
pending on age would, in theory, increase 
the sensitivity of PSA for younger pa- 
tients, and increase specificity for older 
men. No comprehensive study has inves- 
tigated the utility of this approach, and 
there is the potential of a huge increase in 
false-positive work-ups in young men 
where the prevalence of disease is low. 

The "PSA velocity" (PSAV) repre- 
sents the rate of change of the PSA value 
over time in an individual patient. It has 
been proposed as a way to discriminate 
prostate cancer from BPH." The pre- 
mises are that cancerous prostates pro- 
duce more PSA than benignly hypertro- 
phied glands and that rapidly developing 
cancers will show a correspondingly rapid 
rise in PSA. This approach has some 
readily apparent difficulties. Establish- 
ing a baseline value of PSA requires 
multiple PSA values in any given patient, 
and the inherent within-patient variation 
makes meaningful measurements diffi- 
cult" The appropriate interval between 
serial PSA tests has not been determined. 
Since PSAV is based entirely on PSA 
values, it necessarily suffers from the 
same inherent deficiencies that make the 
PSA such a problematic test itself. 

Finally, the various bound forms of 
PSA in serum are being investigated but 
such tests are not yet clinically useful.^ 
The measurement of free (not protein- 
bound) PSA in the serum has also been 
proposed as a possible screening test for 
prostate cancer.*^ 

Can an appropriate population of high- 
risk patients be identified to undergo 
screening? 

Possibly. The cause of prostate cancer is 
not known. Epidemiologic assessments 
point to family history and race as clini- 
cally important factors. A history of pros- 
tate cancer in first-degree male relatives 
increases risk modestly,^' and a high-risk 
gene, which may be responsible for up to 
9% of all family clusters of prostate can- 
cer, has been described.^ The incidence 
of prostate cancer in African- American 



men is 120 times greater than in Asian- 
American men," but this apparent racial 
difference is complicated and may not be 
nearly as important as environmental, 
dietary, and socioeconomic factors (the 
incidence rates in both African-Ameri- 
can and Asian- American men are much 
higher than in native Africans or Asians'). 
The large database of the American Can- 
cer Society's Surveillance, Epidemiol- 
ogy and End Results (SEER) program 
does not confirm racial disparity (it gives 
the lifetime probability of developing 
prostate cancer as 8.7% for whites and 
9.4% for blacks'^). Recent reports imply 
that blacks have a greater age-adjusted 
chance of developing prostate cancer," 
and have shorter survival rates.* 

Do the benefits of screening Justify the 
costs of the screening strategy? 

Who knows? At present, no screening test 
for prostate cancer is sufficiently accu- 
rate. In addition, there is evidence that 
patients whose limited-stage prostate can- 
cer is left untreated survive as well as 
those that are treated. A recent study of 
the cost-effectiveness of prostate cancer 
screening'* applied the Medicare Re- 
source Based Relative Value Scale 
(RBRVS), and national average Medi- 
care allowed charges (MAC) to the stud- 
ies of Richie" and Catalona.'* By setting 
charges for PSA = $29.36, DRE = $5, 
urologyreferraI=$69.62,TRUS=$85.56, 
prostate biopsy = $ 125.50, and pathology 
= $54.46, the authors found that prostate 
cancer screening was at least as cost- 
effective as breast cancer screening. The 
preceding estimates may be low, since at 
another institution, the charge for PSA 
testing is around $80 and the charges for 
TRUS and prostatic needle biopsy around 
$1,500." 

One unfortunate consequence of PS A 
screening as presendy done is the great 
number of false-positive results which 
have both monetary as well as quality-of- 
life-related consequences.' Published es- 
timates say that a one-time PSA screen- 
ing of the population of US men over age 
50 would cost between $12 billion and 
$28 billion." A recent decision analysis 
using quality-of-life preferences recom- 
mended against annual screening of a- 



symptomatic men.* Finally, a study by 
the Group Health Cooperative of Puget 
Sound concluded that screening their 
population by PSA testing would lead to 
total care costs of about $56 million." 



Recommendations 
and Conclusions 

There is no consensus, nationally or in- 
ternationally, for routine prostate cancer 
screening. The American Cancer Society 
and the American Urologic Association 
recommend DRE plus PSA annually be- 
ginning at age 50 years (40 years for men 
at increased risk). The International Union 
against Cancer, the US Preventive Ser- 
vices Task Force, and the Canadian Task 
Force have not endorsed routine screen- 
ing for prostate cancer. The National 
Cancer Institute says that there is too little 
evidence about mortality reduction from 
prostate cancer screening and therefore 
advocates neither for nor against it 

There still are no screening tests that 
will reliably help us differentiate patients 
who have asymptomatic prostate cancer 
from those who do not Furthermore, we 
still have no way to determine which 
patients with limited-stage prostate can- 
cer will be at risk for progression of their 
disease and therefore require treatment 
It will be years until definitive proof is 
available from the randomized trials pres- 
ently ongoing. Some experts advocate an 
aggressive screening approach, empha- 
sizing the need to do everything possible 
to lower the risk of cancer until those 
study results are available. Others, in 
equally persuasive rhetoric, question both 
whether the health benefits of prostate 
screening strategies outweigh its risks 
and the costs in a world of shrinking 
resources. They find that the "burden of 
proof has not been met 

Ultimately, the practitioner must 
decide whether or not to screen for pros- 
tate cancer. Establishing that health ben- 
efits arise from screening requires dem- 
onstrating that screening decreases pros- 
tate cancer-specific mortality rates. At 
present these data do not exist I believe 
that we should continue to hold off on 
mass screening for prostate cancer. □ 



NCMJ / January 1996, Volume 57 Number 1 49 



References 

1 Wong JG, Feussner JR. Screening for 
prostate cancer: does it make a differ- 
ence? NC Med J 1993;54(11):568-71. 

2 Wong JG, Feussner JR. Screening for 
asymptomatic disease in your patients: 
practical tips for doing it right. NC Med J 
1993;54:214-21. 

3 Wingo PA, Tong T, Bolden S. Cancer 
statistics, 1995. CA 1995;45(l):8-30. 

4 Boring CC, Squires TS, Tong T. Cancer 
statistics, 1993. C A 1993;43:7-26. 

5 Carter HB, Coffey DS The prostate: an 
increasing medical problem. Prostate 
1990;16:39^8. 

6 Stamey TA, Freiha FS, McNeal JE, et al. 
Localized prostate cancer: relationship of 
tumor volume to clinical significance of 
prostate cancer. Cancer 1993;71:933-8. 

7 Epstein Jl, Paull G, Eggleston JC, Walsh 
PC. Prognosis of imtreated stage A 1 pro- 
static carcinoma: a study of 94 cases with 
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8 Meikle AW, Smith JA. Epidemiology of 
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9 Resnick MI, Bagshaw MA, Door FA, et 
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10 Chodak GW, Keller P, Schoenberg H. 
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11 Johansson, JE, Adami HO, Andersson 
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12 Chodak GW, Thisted RA, Gerber GS, et 
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13 Grizzle WE, Myers RB, Arnold MM, 
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1994:19:259-66. 

14 Scardino PT Early detection of prostate 
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15 Walther PJ. Prostate cancer screening: 
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16 Wynder EL, Mabuchi K, Whitmore W. 
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Cancer 1971;28:344-60. 

17 Montie JE, Wood DP Jr, Pontes JE, et al. 
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cystoprostatectomy specimens removed 
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18 Wilt T, Brawer MK. The prostate cancer 
intervention versus observation trial: a 
randomized trial comparing radical 
prostatectomy versus expectant manage- 
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ized prostate cancer. J Urol 1994:152: 
1910-4. 

19 Schroder FH. The European screening 
study for prostate cancer. Can J Oncol 
1994;4(suppl l):102-5. 

20 Gohagan JK, Prorok PC, Kramer BS, 
Comett JE. Prostate cancer screening in 
the prostate: lung, colorectal, and ovarian 
cancer screening trial of the National 
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21 Catalona WJ, Smith DS, Ratliff TL, et al. 
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22 Benson MC, Whang IS, Pantuck A, et al. 
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23 Benson MC, Whang IS, OIssonCA,etal. 
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24 Brawer MK, Aramburu EAG, Chen GL, 
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25 Osteriing JE, Jacobsen SJ, Chute CG, et 
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26 Carter HG, Pearson, JD, Metter EJ et al. 
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27 RiehmannM, Rhodes PR, Cook TD,etal. 
Analysis of variation in prostate si>ecific 
antigen values. Urology 1993;42:390-7. 

28 Lilja H, Crocket AT, Abrahamsson PA. 
Prostate specific antigen predominately 



forms a complex with alpha 1-anti- 
chymotypsin in blood. Implications for 
procedures to measure prostate specific 
antigen in serum. Cancer 1992; 70:230-4. 

29 Cannon L, Bishop DT, Skolnick M, et al. 
Genetic epidemiology of jjrostate cancer 
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Surv 1982;1:47-69. 

30 Carter BS, Beaty TH Steinberg GD, et al. 
Mendelian inheritance of familial pros- 
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1992;89:3367-71. 

31 Boring CC, Squires TS, Heath CW Jr. 
Cancer statistics of African Americans. 
CA 1992;42:7-18. 

32 Siedman H, Mushinski MH, Geib DK, 
Silverberg E. Probabilities of eventually 
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36-56. 

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Cancer statistics review 1973-1988. NIH 
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34 Benoit RM, Naslimd MJ. An economic 
rationale for prostate cancer screening. 
Urology 1994;44(6):795-803. 

35 Richie JP, Catalona WJ, Ahmann FR, et 
al. Effect of patient age on early detection 
of prostate cancer with serum prostate- 
specific antigen and digital rectal exami- 
nation. Urology 1993;42:365-74. 

36 Catalona WJ, Smith DS,RatliffTL, Easier 
JW. Detection of organ confined prostate 
cancer is increased through prostate-spe- 
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1993;270:948-54. 

37 Barry MY, Reming C, Coley CM, et al. 
Should Medicare provide reimbursement 
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early detection of prostate cancer? Part I: 
framing the debate. Urology 1995;46:2- 
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38 Cantor SB, Spann SJ, Volk RJ, Cardena 
MP, Warren MM . Prostate cancer screen- 
ing: a decision analysis. J Fam Prac 
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39 Handley MR, Stuart ME. The use of pros- 
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Urol 1994;152:1689-92. 

40 Catalona WJ, Smith DS,WolfertRL,etal. 
Evaluation of percentage of free serum 
prostate-specific antigen to improve speci- 
ficity of prostate cancer screening. JAMA 
1995;274:1214-20. 



50 



NCMJ / January 1996, Volume 57 Number 1 



New Members 



Adegboyega Olufemi Aderibigbe (RES), 304 

Brandermill Drive, Durham 27713 
Karen Louise Bash (ORG), 2438 Komegay 

Place, Chapel Hill 27514 
Natalie Carmen Beltran (RES), 910 Constitu- 
tion Drive, #1005, Durham 27705 
Anita Louise Blosser (FP), 1912 Ruin Creek 

Road, Ste. 101, Henderson 27536 
David Wayne Brown (RES), NCBH, Dept. of 

Radiology, Medical Center Blvd., Winston- 
Salem 27157 
Lucy Jean Brown (PD), 1312 CarroU St., 

Durham 27707 
Carlin Bullard (STU), 2220 Queen St., Win- 
ston-Salem 27103 
Linda Hipp Butler (PD), Capitol Pediatric 

Center, 3801 Computer Drive, Raleigh 

27609 
James Carl Cook, Jr. (C), 122JoUy St., #101, 

Louisburg 27549 
Sue Ellen Cox (D), 11 low. MainSt., Durham 

27701 
John Cromartie Crawley (PHYS ASST), 1803 

Kelly St., Fayetteville 28305 
Christopher MacDonald Debacker (RES), 

Duke Eye Center, Durham 27710 
Douglas Ray Dirschl (ORS), Wake AHEC, 

3024 New Bern Ave., Ste. 302, Raleigh 

27610 
David R. Ficklen (RES), 1919 Hinshaw Ave., 

Winston-Salem 27104 
Thomas Geoffrey Folk (RES), 23 1 1 Harrison 

Drive, Burlington 27215 
William Earl Fox (RES), 3326 Lassiter St., 

Durham 27707 
Edward Scott Frankel (RES), 2504 Yorkdale 

Court, Durham 27707 
Luther Wayne Freas (PHYS ASST), 3308 

Chalmers Drive, Wilmington 28409 
Sujau Vijay Ghate (RES), 28 Holland Drive, 

Chapel Hill 27514 
Joseph Emmett Giddings, m (PHYS ASST), 

203 Crescent Drive, Windsor 27983 
Patrick Lee Godwin, Jr. (RES), 440 Smith 

Road, Rougemont 27572 
Magnus Gottfredsson (RES), Box 31171, 

DUMC, Durham 27710 
Samuel Marc Grossinger (PHYS ASST), 3307 

Park Overtook Drive, Durham 27712 
Dona Marie Grzywacz (PHYS ASST), 1756 

Metromedical Drive, Fayetteville 28304 
Gregory Alan Hasen (OBG), 5 10 S. South St., 

Mount Airy 27030 



Debbie Adams Hauser (PHYS ASST), 5739 

Whippoorwill Drive, Pfafftown 27040 
Michael John Hilts (RES), 1125 N. Church 

St., Greensboro 27401 
Terrance Lee Hough (AN), 1407 Canal Drive, 

Sunset Beach 28468 
George Charles Hughes, IV (RES), 54 

Stoneridge Road, Durham 27705 
Harry Turner Hulbert (PHYS ASST), 101-H 

Quail Lakes Drive, Winston-Salem 27104 
Tahmida Jahangir (PD), 424 Harlow Drive, 

FayettevUle 28314 
Joseph Anthony Jaskolski (RES), Carolinas 

Medical Center, P.O. Box 3286 1 , Charlotte 

28232 
John Lawrence Jimenez (RES), 361 1 Univer- 
sity Drive, #10P, Durham 27707 
Sharon Francis Kane (RES), 656 Larkspur 

Drive, Fayetteville 2831 1 
Bobby Paxton Kearney (AN), 503 Mills Gar- 
den, Statesville 28677 
Katrina Lynn Kelly (OBG), 6350 Quadrangle 

Drive, Chapel Hill 27514 
Letitia Parker Kinloch (STU), 223 VaUey Park 

Drive, Apt. 2, Chapel Hill 27514 
Christopher Jon Kratachvil (RES), Box 2906, 

DUMC, Durham 27710 
Kevin Richard Kruse (RES), 3020 Synnotts 

Place, Durham 27705 
Muriel Lynn Webber Lamoureux (PHYS 

ASST), Wake Rehab. Hospital, 3000 New 

Bern Ave., Raleigh 27610 
Laurie Wilson Lee (PHYS ASST), Center For 

Women, 407 Crutchfield St., Durham 27704 
Robert Warren Letton, Jr. (RES), 2449 

Ardmore Manor, Winston-Salem 27103 
Diana Renee Lewis (RES), 1 18 W.T. Weaver 

Blvd., Asheville 28801 
Laura Ross Loehr (RES), 75 16 Parkdale Ave. 

1 East, Clayton MO 63105 
Mark Anthony Mattioh (RES), 1 108 Chowan 

Ave., Durham 27713 
KeUi Burgin Mayfield (FP), Sloop Memorial 

Hospital, P.O. Box 567, Crossnore 28616 
Thomas Eddison Maynor, II (STU), Route#l, 

Box 442-1, Greenville 27834 
James Whitman Mims (RES), 607-B S. 

Hawthorne Road, Winston-Salem 27103 
Veda Louise Jovonavich Moore (OPH), 301 

Bowman Gray Drive, Greenville 27858 
Lawrence Howard Nabors (GS), 180 N. 

Parkwood Drive, Elkin 28621 
Douglas Frederick Obenrader (PHYS ASST), 



P.O. Box 955, Coats 27521 
David Thomas Outlaw (STU), 1617 Ham- 
mock Place, Raleigh 27606 
Howard WilliamPalay(N), 102 Hospital Drive, 

Ste. #1, Clyde 28721 
Lisa Fay Patterson (RES), 5610 Laurel Crest 

Drive, Durham 27712 
John Ethwell Ramsey Perry, HI (IM), 3000 

New Bern Ave., Raleigh 27610 
George Peter Poletes (RES), 1000 Smith Level 

Road, Apt. C4, Carrboro 27510 
Teresa Lynn Pusheck (OTO), 1 1 10 W. Main 

St., Durham 27705 
Martha Feher (RES), 903 Cedar Fork Trail, 

Chapel HUl 27514 
Michael Edward Richards (STU), 102 

Westmont Drive, Greenville 27858 
John Jay Robbins (PHYS ASST), 2810 

Maplewood Ave., Winston-Salem 27103 
Charles A. Sanders (IM), 3200 Rugby Road, 

Durham 27707 
Brian Howard Schactman (RES), 606 

Remington Circle, Durham 27705 
Brian Kiesnowski (RES), 126 Victoria Court, 

Unit D, Greenville 27834 
Ronald Fong Sing (GS), Carolinas Medical 

Center, P.O. Box 32861, Charlotte 28232 
Djonggi Wirjadi Situmeang (FP), 171 W. 

Wilkes, Medical Center Road, Ferguson 

28624 
Susan Elizabeth Smith (RES), 902 Balfoure 

Drive, Wilmington 28412 
Elizabeth Brooke Sp)encer (RES), 346 Standish 

Drive, Chapel Hill 27514 
Kelly Ann Stambaugh (PHYS ASST), 199 

Cardinal Road, Murphy 28906 
Francis Joseph Stranick(PD), 200 Hawthorne 

Lane, Charlotte 28211 
Suzonne Denise Ijames Stratton (PHYS 

ASST), 4260 Glenn High Road, Winston- 
Salem 27107 
Christopher John Vesy (RES), 3708-P 

Meriwether Drive, Durham 27704 
David Keith Wallace (PO), UNC, 6 1 7 Bumett- 

Womack, Chapel Hill 27599 
David Allan Weinrib (ID), P.O. Box 32861, 

Charlotte 28232 
John Clifton Wellons, III (RES), 13A 

Riverbirch Road, Durham 27705 

Alamance-Caswell 

Martin A. DeFrancesco (OBG), Westside OB/ 
GYN Center, PA, 1091 Kirkpatrick Road, 



NCMJ / January 1996. Volume 57 Number 1 51 



Burlington 27215 
David Campbell Gerlach (EM), 3615 Surry 

Trail, Hillsborough 27278 
Ronnie Lynn Jacobs (IM), Ste. 3100, 1236 

Huffman Mill Road, Burlington 27215 

Buncombe 

Jorge Luis Carreras (FP), 206 Asheland Ave., 

Asheville 28801 
Wendy Kathryn Coin (FP), 206 Asheland Ave., 

Asheville 28801 
Hugh Duncan Dorris, Jr. (D), 390 S. French 

Broad Ave., AsheviUe 28801 
Carlton TrentFaulk(D), 78 Long Shoals Road, 

Arden 28704 
George Lowndes Harrison (Ro), Mountain 

Radiation Oncology, PA, 200 Doctors Bldg., 

Asheville 28801 
Michael David Stephens (FP), 2161 

Hendersonville Road, Arden 28704 

Burke 

Jonathan CardeenLowry(OPH), 335 E. Parker 
Road, Morganton 28655 

Cabarrus 

Susan Ruth Andersen (FP), 1118 Setter Lane, 

Concord 28025 
David Uri Lipsitz (U), 102 Lake Concord 

Road, Concord 28025 
Samuel A. NickeU (OS), 320-D Copperfield 

Blvd., Concord 28025 
Eric J. Panner (OBG), 815 Wentworth Court, 

Concord 28025 
Ronald A. Pollack (FP), 5601 Silchester Lane, 

Charlotte 28215 
Mark Anthony Vincent (FP), 8560 Cook St., 

Mount Pleasant 28124 
Patricia Schaffer White (FP), 112 Woodland 

St., P.O. Box 1874, Davidson 28036 

Caldwell 

Peter Chun-Kit Ho (U), 328 Mulberry St., SW, 

Lenoir 28645 
Thomas Wendell Prewitt, Jr. (GS), P.O. Box 

1648, Lenoir 28645 

Carteret 

Robert James Brockman (GS), 306 Penny 
Lane, Morehead City 28557 

Catawba 

Geoffrey Donald Deleary (U), 1202 N. Center 

St., Hickory 28601 
Harold Charles Dufour (OBG), P.O. Box 38, 

Fairgrove Church Road, Hickory 28603 
Steven Allen Gold (FP), P.O. Box 368, Maiden 

28650 
Peter Daniel MiUer (NS), 415 N. Center St., 

Ste. 301, Hickory 28601 
Thomas Reginald Williams (OPH), P.O. Box 

2588, Hickory 28603 



Craven-Pamlieo-Jones 

Robert William Monteiro GM), P.O. Box 68, 
PoUocksville 28573 

Cumberland 

Surajit Chaudhuri (IM), 224-E Partners Way, 

Fayetteville 28314 
Samuel A. Fleishman (P), 604 Ravencroft 

Court, Fayetteville 28314 
Bruce Paul Jaufmann (NS), 3314 Melrose 

Road, Ste. 104, Fayetteville 28304 
Val h Prasad Kodali (GE), 1 73 8 Metromedical 

Drive, Fayetteville 28304 

Durham-Orange 

James M. Adams (STU), 200 Barnes Sl, Apt 

15-E,Carrboro 27510 
Toyin Ajose (STU), N-101 Ramsgate Apts., 

Carrboro 27510 
Alvin K. Antony (STU), 1 1 2-C Purefoy Road, 

Chapel Hill 27514 
Victor Archie (STU), 10-A Royal Park, 

Canboro 27510 
Paul Armistead (STU), 105-F Mistywood 

Circle, Chapel Hill 27514 
Peggy A. Becker (STU), 4 1 24 Peachway Drive, 

Durham 27705 
Jonathan S. Berg (STU), 875 Airport Road, 

#15, Chapel Hill 27514 
M. Angelyn Bethel (STU), 3222-G Myra St., 

Durham 27707 
Trey Blazer (STU), 203 Mindenhall Way, 

Gary 27513 
Brian Broome (STU), 605 Jones Ferry Road, 

Apt. R-4, Carrboro 27510 
Latonya A. Brown (STU), 404 Jones Ferry 

Road, B-16, Carrboro 27510 
ChuckBrowning (STU), 2206 Marlowe Drive, 

Durham 27705 
Stephanie R. Bruce (STU), 14-F Post Oak 

Road, Durham 27705 
Daniel Rogers B urnett (STU), 1 -A River Birch 

Road, Durham 27705 
Craig Bumworth (STU), 21 Holland Drive, 

Chapel Hill 27514 
Ellen Calhoun (STU), 608 Sugarberry Road, 

Chapel Hill 27514 
H. Scott Cameron (STU), 104 Sanair Court, 

Apex 27502 
Donna Capps (STU), 2525 BookerCreek Road, 

Apt. 3E, Chapel Hill 27514 
Dean C. Carlow (STU), 110 Lantern Way, 

Carrboro 27510 
Carolyn CeU (STU), 708 Greenwood Road, 

Chapel Hill 27514 
Nicole Chaisson (STU), 108-A William St, 

Carrboro 27510 
Kirk L. Charles (STU), 618 LaSalle St., #6A, 

Durham 27705 
Elbert Tzechin Chen (STU), 5-D Post Oak 

Road, Durham 27705 
Michael Cody (STU), 601 Jones Ferry Road, 



#J-5, Canboro 27510 
Rom Colindres, Jr. (STU), 220 McCauley St., 

Apt. B, Chapel Hill 27514 
David A. Coolidge, Jr. (STU), P.O. Box 98400, 

Durham 27708 
Keenya Crawford (STU), 5639 Chapel Hill 

Road, Apt. 103, Durham 27707 
Brian R. Crichlow (STU), 11-C Post Oak 

Road, Durham 27705 
Kenneth Crosby (STU), 1000 Smith Level 

Road, Carrboro 27510 
Marco Davila (STU), IC Post Oak Road, 

Durham 27705 
Daniel De Meyts (STU), 3601-L Highgate 

Drive, Durham 27713 
Deanne Degreaffenreidte (STU), 903 Dawes 

Sl, Apt. A, Chapel HiU 27516 
Kendreia W. Dickens (STU), 4216 Ganett 

Road, HI 4, Durham 27707 
Stephen M. Dingman (STU), 3171 Exacta 

Lane, #113, Raleigh 27613 
Xiang Da (Eric) Dong (STU), 5-D Post Oak 

Road, Durham 27705 
Kelly Elise Dooley (STU), 829 Wilkerson 

Ave., Durham 27701 
Stanley F. Dover (STU), 605 Jones Ferry 

Road, Apt. T2, Carrboro 27510 
Lara B. Eisenberg (RES), 7303 Calibre Park 

Drive, #201, Durham 27707 
Derek Elliott (STU), 135-AJohnsonSt.,Chapel 

Hill 27516 
Susanne M. Engler (STU), 910 Constitution 

Drive, Apt. 508, Durham 27705 
Melvin S. Farland, Jr. (STU), 201 Westbrook 

Drive, Apt. Bl, Carrboro 27510 
John Charles Finn (OTO), 1 1 10 W. Main SL, 

Durham 27701 
Lisa Flora (STU), 601 Jones Ferry Road, ApL 

B-5, Carrboro 27510 
Kymberiy Floyd(STU), 601 Jones Ferry Road, 

Apt. F-4, Carrboro 27510 
Susan Gibbs (STU), 104 Laurel Hill Road, 

Chapel HUl 27514 
Sean Christopher Glasgow (STU), 2748 

Middleton Ave., ApL 18G, Durham 27705 
Nikki L. Graves (STU), 1 1 F Royal Park Apts.. 

501 Hwy. 54 Bypass, Carrboro 27510 
John Lawrence Gray (VS), Box 3211, DUMC, 

Durham 27710 
Tamara Green (STU), 1000 Smith Level Road, 

Apt. D-3, Carrboro 27510 
Herb Greenman (STU), 12-B River Birch 

Road, Durham 27705 
TinaR.Griffin (STU), 209 Conner Drive, ApL 

5, Chapel Hill 27514 
AngelisaGrogan (STU), 334-A Mann's Chapel 

Road, Chapel HUl 27516 
Elizabeth Gardner Grubbs (STU), 4D Post 

Oak Road, Durham 27705 
Kimberiy Gush (STU), 604 TinkerbeU Road, 

Chapel HUl 27514 
Harvey Hamrick (STU), 103 Forest Court, 



52 



NCMJ / January 1996, Volume 57 Number 1 



Carrboro 27510 
Christina Hardin (STU), 209 Conner Drive, 

Apt. #4, Chapel Hill 27514 
Geoffrey R. Hanis (STU), lA River Birch 

Road, Durham 27705 
Janet Harris (STU), Route #9,Box 392, Chapel 

Hill 27514 
Angle Rena Harshaw (STU), 200 Barnes St., 

Apt. 15A, Carrboro 27510 
Jonathan A. Hata (STU), 3224 Myra St., Apt. 

B, Durham 27707 
Shilpa M. Hattangadi (STU), 311 S. LaSalle 

St., Apt. 43-1, Durham 27705 
Michael J. Healey (STU), 6-D River Birch 

Road, Durham 27705 
Kerrie-Anne Heron (STU), 12-H River Birch 

Road, Durham 27705 
Vicki Herriott (STU), 142 St. Andrews Lane, 

Chapel Hill 27514 
Claire Holland (STU), 233 Butler Court, 

Chapel Hill 27514 
Joel Horowitz (GS), 3901 Roxboro St., Durham 

27704 
Tracey L. Huckabee (STU), 1479 Ephesus 

Church Road, Chapel Hill 27514 
Tyehimba Afrika Hunt (STU), 200 Barnes St., 

lA University Lake Apts., Carrboro 27510 
Brian Jaquette (STU), 1301 Rosemary Ave., 

Durham 27705 
Ryan Jessup (STU), 605 Jones Ferry Road, 

Apt. R8, Carrboro 27510 
Bobby Johnson, Jr. (STU), 2701 Homestead 

Road, Apt. 105, Chapel HiU 27514 
Dawn Denise Johnson (STU), 547-A Lystra 

Road, Rt. 9, Chapel Hill 27514 
Cory Jones (STU), 311 S. LaSalle St. Apt. 

33P, Durham 27705 
Karen Vickers Jones (ORS), 3901 Roxboro 

Road, Durham 27704 
Sarah Jordan (STU), 306 Estes Drive, Ext. 

Apt. 14Q, Carrboro 27510 
William Lawrence Joyner (RES), Route #2, 

Box 144, Spring Hope 27882 
Warren Ross Kadrmas (STU), 11 Willow 

Bridge #49, Durham 27707 
Scott Kane (STU), 31 1 S. LaSalle St., Apt. 1- 

H, Durham 27705 
John Kang (STU), 122 Mallard Court, Chapel 

HiU 27514 
Andrew Kaz (STU), 1302 Shepherd St., 

Durham 27707 
Sosena Kebede (STU) , UNC, 238 Craige Hall, 

Chapel Hill 27599 
Josh Knowles (STU), 201 Howell St., Apt. 

ID, Chapel Hill 27514 
Tommy Koonce (STU), 1 37-B Purefoy Drive, 

Chapel Hill 27514 
David K. Krzymowski (STU), 3454 Sandy 

Creek Drive, Durham 27705 
AnitaKuo(STU),5-G Post OakRoad, Durham 

27705 
Julie E. Lang (STU), 1 1 6-1 Shadowood Drive, 



Chapel Hill 27514 
Harry M. Lightfoot (STU), 601 Jones Ferry 

Road, #E9, Carrboro 27510 
Kevin J. Logel (STU), 105 Fidelity St., Apt. 

A31, Carrboro 27510 
Kathryn Elizabeth Long (STU), 1 36-A Purefoy 

Road, Chapel HUl 27514 
Marchi Lopez-Linus (STU), 1 106 Roosevelt 

Drive, Chapel Hill 27516 
Angela D. Lowe (STU), 620 Airport Road, 

Apt. 301, Chapel HiU 27514 
Leigh C.Masten (STU), 1 80 BPW Club Road, 

Apt. P-10, Highland Hills, Carrboro 27510 
Mara Matula (STU), 104 MelviUe Loop, Apt. 

24, Chapel HUl 27514 
Kelvin McKoy (STU), 5639 Chapel Hill Road, 

#510, Durham 27707 
Ben M. Meares, Jr. (STU), 127-B North St., 

Chapel HUl 27514 
Nathan Woodbum Mick (STU), 10 Post Oak 

Road, Apt. G, Durham 27705 
Robert Sean Miller (STU), 6 Weathergreen 

Court, Durham 27713 
William A. Mills, Jr. (STU), 111-D 

Weatherstone Drive, Chapel HUl 27514 
Stephen Moff (STU), 2920 Chapel Hill Road, 

Apt 52-B, Durham 27707 
Suk Jin Moon (STU), Box 2816, DUMC, 

Durham 27710 
Zack Moore (STU), 13 Davie Circle, Chapel 

HiU 27514 
SandraP. Moreira(STU), 713 SnowcrestTrail, 

Durham 27707 
Mokhtar Morgan (STU), 306 Estes Drive, #0- 

1, Carrboro 27510 
Nancy Strom Morgan (STU), 9 Meadhall 

Court, Durham 27713 
Radhika G. Murty (STU), 602 S. Columbia 

St., Chapel Hill 27514 
Marie Nash (STU), 110 Cameron Court, 

Chapel HUl 27516 
Melissa Lorraine Neal (STU), 130 S. Estes 

Drive, Apt. 1 1-A, Chapel HUl 27514 
Harriet A . Neely (STU), 1 40 B PW Club Road, 

Apt. F-10, Carrboro 27510 
Patrick O'Connell (STU), 4 Brandon Road, 

Chapel mil 27514 
Ty J. Olson (STU), 1915 Yearby St., Apt. I, 

Durham 27705 
Marion Kaylor Owen (STU), 1250 Ephesus 

Church Road, D-5, Chapel HiU 27514 
Elvis Pagan (STU), 907 Alexander Stewart 

Road, HUlsborough 27278 
Cathleen L. Peterson, (STU), 1315 Morreene 

Road, #25-G, Durham 27705 
Levonne Powell (STU), 306 N. Estes Drive, 

Ext. lO-I, Carrboro 27510 
Jeffrey Ralph (STU), 312 McCauley St. Apt. 

D, Chapel HiU 27516 
Beth Renzulh (STU), 815-A Old Pittsboro 

Road, Chapel HUl 27516 
Jay Reynolds (STU), 206 Cedarwood Lane, 



Carrboro 27510 
Tara Rice (STU), 50 Brithey Court, Durham 

27713 
WU Ham J . Rosa (STU) , 1 1 05 H wy . 54 Bypass, 

Apt. 12G, Chapel HiU 27516 
AUison B . Rosen (STU), 2721 Dogwood Road, 

Durham 27705 
Daniel R. Scanga (STU), 1915 Yearby St., 

Apt. I, Durham 27705 
Scott Schobel (STU), 234 Craige Hall, UNC, 

Chapel HUl 27599 
Lara Setti (STU), 612 Hillsborough St. #23, 

Chapel HiU 27514 
Nimesh B. Shah (STU), 3226-A Myra St., 

SouUi Point Apts., Durham 27705 
AUison Shivers (STU), 602 1/2 S. Columbia 

Sl#C, Chapel HiU 27514 
Donovan Simmons (STU), 1100 Hwy 54 By- 
pass, #25H, Chapel HiU 27516 
Graham Snyder (STU), 1 1 1 Buena Vista Way, 

Chapel HUl 27514 
Arleen H. Song (STU), 140 BPW Club Road, 

Apt. B-13, Carrboro 27510 
ChanhUievy Sourisak (STU), 214 Pittsboro 

St., Chapel HiU 27516 
Suzanne E. Strandhoy (STU), 706 The Oaks 

Apts., Chapel HUl 27514 
AmishSura(STU), 108EphesusChurchRoad, 

514 HamUn Park, Chapel HUl 27514 
Knox R. Tate (STU), 24 HoUand Drive, Chapel 

HiU 27514 
John D. Temple (STU), 24 Holland Drive, 

Chapel HUl 27514 
Barbara Thiede (STU), 114 Friar Lane, 

Carrboro 275 10 
Yalaunda M. Thomas (STU), 501 Hwy. 54 

Bypass, Royal Park Apts. , 1 1 F, Chapel HiU 

27516 
Christopher Thompson (STU), 108 Duchess 

Lane, Chapel HiU 27514 
C. John Torontow (STU), 266 Severin St., 

Chapel HUl 27516 
L. Gerard Toussaint, m (STU), 408 Ransom 

St., Chapel HiU 27514 
Harrison G. Tutde (STU), 223 McCauley St. 

#8, Chapel HUl 27516 
Joy M. Twersky (STU), 3206-G Myra St, 

Durham 27707 
BeUi Underwood (STU), 201 -A Purefoy Road, 

Chapel Hill 27514 
Tracie A. Walker (STU), 315 W. University 

Drive, Chapel HUl 27516 
Karen M. Warburton (STU), 1100 Highway 

54 Bypass, Apt. #87, Chapel HiU 27516 
Paula Watke (STU), 910 Constitution Drive, 

#703, Durham 27705 
John W. Watts (STU), 907 Alexander Stewart 

Drive, Hillsborough 27278 
Eric Charles Westman (IM), 125 Radcliff 

Circle, Durham 27713 
Peter G. Whang (STU), 1108 SnowcrestTrail, 

Durham 27707 



NCMJ / January 1996, Volume 57 hi umber 1 53 



Jonathan Williams (STU), V-3 Highland Hills, 
180 BPW Club Road, Cairboro 27510 

Brooke Winkle (STU), 3 Preakness Drive, 
Durham 27713 

Stewart S. Worrell (STU), 4800 University 
Drive, Apt. 28F, Durham 27707 

Forsyth-Stokcs-Davie 

Jorge Juan Asconape (N), 1 60 Charlois Blvd., 
Winston-Salem 27103 

Angela Aslami (STU), 1 832 Stonewood Drive, 
Winston-Salem 27103 

AndreaLeigh Bennett-Cain (STU), 1 120Ebert 
St., Winston-Salem 27103 

Robert Chin, Jr. (PUD), Bowman Gray School 
of Medicine, Medical Center Blvd., Win- 
ston-Salem 27157 

Stephen Bernard Clyne (STU), 211 -A Mag- 
noUa St., Winston-Salem 27103 

Jennifer Lynn Druckenmiller (STU), 1243 
Wedgewood Drive, Winston-Salem 27103 

Roland Morris Friedman (U), 1806 S. 
Hawthorne Road, P.O. Box 24369, Win- 
ston-Salem 27114 

Anna Geltser (STU), 2357-D Ardmore Ter- 
race, Winston-Salem 27103 

Marcus Ward Gillikin (STU), 3826-H Coun- 
try Club Road, Winston-Salem 27104 

Leanne Groban (RES), 4755 Country Club 
Road, 113G, Winston-Salem 27104 

Morrill Elizabeth Harrington (STU), 839 
Lockland Ave., Winston-Salem 27103 

Robert Duncan Hite (PUD), Bowman Gray 
School of Medicine, Medical Center Blvd., 
Winston-Salem 27157 

Steven Samuel Hughes (ORS), Bowman Gray, 
Dept.Ortho.Surgery, Medical CenterBlvd., 
Winston-Salem 27157 

RadhikaJayaraj (STU), 1 904 Gaston St., Win- 
ston-Salem 27103 

Robert Frederic Leinbach (STU), 1408 Clover 
St., Winston-Salem 27101 

Joseph Andrew Molnar (PS), Bowman Gray 
School of Medicine, Medical Center Blvd., 
Winston-Salem 27157 

Eric Thomas Mullen (STU), 3380 Poteat Court, 
Winston-Salem 27106 

Victoria Mitchell Payne (STU), 2813 Betha- 
bara Park Blvd., Winston-Salem 27106 

Robert Bruno Preli (STU), Bowman Gray, MS 
2917, Medical Center Blvd., Winston-Sa- 
lem 27157 

AnneMarie Elizabeth Puckhaber(STU), 1832 
Stonewood Drive, Winston-Salem 27103 

William DavidSchneickert(STU), 1048 Mag- 
noha St., Winston-Salem 27103 

James David Steed, Jr. (STU), 4830 Thales 
Road, Apt. C, Winston-Salem 27104 

Jason Hirst Turner (STU), 2001 Northcliffe 
Drive, #415, Winston-Salem 27106 

Nancy Katherine Wahls (STU), MS 2947, 
Bowman Gray, Medical CenterBlvd., Win- 



ston-Salem 27157 
Jennifer Bennett Wares (STU), 17-A Sum- 
mertree Lane, Greensboro 27406 

Gaston 

Charles Kanayo Agunobi (IM), 2519 Ozark 

Ave., Gastonia 28054 
Rinelda Maraikia Horton (ORS), 902 Cox 

Road, Ste. A, Gastonia 28054 

Greater Greensboro Society of Medicine 

Joseph Peter Drozda, Jr. (AMM), 2307 W. 

Cone, Ste. 200, Greensboro 27408 
Richard Eric Guice (OBG), 721 Green VaUey 

Road, Ste. 200, Greensboro 27408 
Ronald Jeffery Pudlo (PD), 510N. Elam Ave., 

Ste. 202, Greensboro 27403 

Halifax-Northampton 

Joy Panackal Thomas (AN), P.O. Box 39, 
Roanoke Rapids 27870 

Henderson 

David P. Allred (IM), Saluda Medical Center, 
Saluda 28773 

William Neville Gee, Jr. (IM), 9 Cross Roads 
Drive, Horse Shoe 28742 

Georgeanne Hoegerman (PD) .P.O.Box 5420, 
52 Doctors Drive, Fletcher 28732 

Douglas Brett HunUey (GS), 835 Fleming St., 
Hendersonville 28791 

William Douglas Medina(HEM), 820 Fleming 
St., Hendersonville 28739 

John Palmer Pickens (OTO), 1998 Hender- 
sonville Road, Ste.40, Asheville 28803 

High Point 

Wilham R. Owings, P.O. Box 2324, High 

Point 27261 
Mark Andrew Rowley (ORS), 624 Quaker 

Lane, Ste. D200, High Point 27262 

Lenoir-Greene 

RichardRalph Durham aM), 109 Airport Road, 

Kinston 28501 
Shyama] Kishore Mitra(C), 701 Doctors Drive, 

Ste. N, Kinston 28501 
Andrew John Siekanowicz (ORS), Kinston 

Clinic North, Ste. G, Kinston 28501 

Lincoln 

Rabindran Israel (PD), 101 Lincoln Medical 
Park, Lincolnton 28092 

Mecklenburg 

David Jon Bilstrom (PM), 1 100 Blythe Blvd., 
Charlotte 28203 

Mary Martha Bledsoe (PD), Eastover Pediat- 
rics, 2600 E. 7th St., Ste. 100, Charlotte 
28204 

Richard Ralph Boesel (OBG), 101 W.T. Har- 
ris Blvd. #2320, Charlotte 28262 



Glenn William ErTington(Ar),271 1 Randolph 

Road, Bldg. 400, Charlotte 28207 
Robert Brian Fazia (Q, 1 71 8 E. 4th St., #501, 

Charlotte 28211 
Patrick Chnton Fenner (C), 1718 E. 4th St, 

#501, Charlotte 28211 
Daniel Karl Howard (PUD), lOOlBlytheBlvd., 

Ste. 500, Charlotte 28203 
David Earl Newman (OBG), 101 W.T. Harris 

Blvd., Ste. 2320, Charlotte 28262 
F. Mack Sexton (PTH), P.O. Box 3286 1 , Char- 
lotte 28232 
Ronald Wayne Singer (ORS), 1001 Blythe 

Blvd., Ste. 200, Charlotte 28203 
Stanton James Smith, 271 1 Randolph Road, 

Ste. 204, Charlotte 28207 
Eugene Guy Tudor (OTO), 1718 E. 4th St., 

Ste. 303, Charlotte 28204 
Stephen John Valder (PD), 427 N. Wendover 

Road, Charlotte 28211 
Robert T. Wicker (OBG), 1023 Edgehill Road 

S., Charlotte 28262 

Moore 

Rodolfo D. Ongjoco, Jr. (P), P.O. Box 846, 

Southern Pines 28388 
Steven Paul Strobel (EM), 1 20 Lakeside Court, 

Pinehurst 28374 

Nash 

Stacey Renee Gouzenne (EM), Route #3, Box 

155-E, Rocky Mount 27804 
Gilbert Gomer Whitmer, Jr. (ORS), 901 N. 

Winstead Ave., Ste. 300, Rocky Mount 

27804 

New Hanover-Pender 

Paul Anthony Buongiomo (P), 1402 S. 17th 
St., Wilmington 28401 

Michael Delane Carter (ORS), 1601 S. Col- 
lege Road, Wilmington 28403 

Jonathan Stuart Crane (D), 1615 Doctors 
Circle, Wilmington 28401 

Laura K. Fijolek (OBG), 1802 S. 17th Sl, 
Wilmington 28401 

Marsha Duke Fretwell (IM), 6320 Head Road, 
WUmington 28401 

James Glenn Lenhart (FP), 5436 Aventuras 
Drive, Wilmington 28409 

Thomas Eric Parent (ORS), Wilmington Or- 
thopaedic Group, 2001 S. 17th St., 
WUmington 28401 

David Thomas Sawyer (Q, 1515 Doctors 
Circle, Wilmington 28401 

Onslow 

Mark Hennessy (IM), 47 Office Park Drive, 
Jacksonville 28546 

Person 

Thomas Antalik (GS), 511 Ridge Road, 
Roxboro 27375 . 



54 



NCMJ / January 1996. Volume 57 Number 1 



Pitt 

Christopher S. Byrd (STU), 1642 Treybrooke 

Circle, Greenville 27834 
Michael P. Coyle (PD), ECU School of Medi- 
cine, Brody Bldg. 3 E, 1 39, Greenville 27858 
Karin Marie Hillenbrand (PD), ECU Dept. of 

Pediatrics, Greenville 27858 
Nancy W. Holland (STU), 734 Milton Drive, 

WintervUle 28590 
FeUcia Duff Hussey (STU), 97 Bayswater 

Road, WinterviUe 28590 
Ulf Lennart Karlsson (RO), ECU, Jenkins 

Cancer Ctr., Moye Blvd., Greenville 27858 
Jerry Lane Lowder (STU), 602-34 Treybrooke 

Circle, Greenville 27834 
John Thomas Meredith (EM), ECU School of 

Medicine, Dept. of Emergency Medicine, 

GreenvUle 27858 
Melissa Gold O'Neal (STU), 510-24 

Treybrooke Circle, Greenville 27834 
JessicaMaria Pinzon (STU), 1222 Treybrooke 

Circle, Greenville 27834 
Sara Lynn Pupilli (STU), K-3 Doctors Park 

Apts., Beasley Drive, Greenville 27834 



Ann Mohney Scott (STU), 2106 Hyde Drive, 
Greenville 27858 

Andrea Megan Thomas (STU), 1 05 N. Library 
St., Greenville 27858 

Peter Brian Wagner (C), Carolina Heart, 804 
Johns Hopkins Drive, Greenville 27834 

Tammy Westmoreland (STU), 2708-4 Merid- 
ian Drive, Greenville 27834 

Joanna Wolicki (STU), 2645-H McGregor 
Downs Road, Greenville 27836 

Polk 

Charles Anthony Staley (FP), 151 Reynolds 
Road, Inman, SC 29349 

Richmond 

JayRamaiilalParikh(ORS), 106 Jefferson St., 

P.O. Box 1226, Hamlet 28345 
Michael William Walker (ORS), P.O. Box 

638, Rockingham 28379 

Robeson 

Amel Hernandez Panelo (IM), 119 N. Flo- 
rence St., Maxton 28364 



Stanly 

Leonard D. Saltzman (FP), 317 Yadkin Sl, 
Albemarle 28001 

Vance 

MichaelGlenDolin(ORS),918 Meadow Lane, 
Henderson 27536 

Wake 

Karen Saville Cannon (PD), 3801 Computer 
Drive, Ste. 200, Raleigh 27613 

Frances Harrington Griffiths (FP), 1 15 S. Rail- 
road St., Benson 27504 

Michael Ross March (OBG), 4420 Lake Boone 
Trail, Ste. 301, Raleigh 27607 

Dennis E. Ose (PTH), Raleigh Community 
Hospital, 3400 Wake Forest Road, Raleigh 
27609 

Richard Howard Pike (ORS), 3 100 Duraleigh 
Road, Raleigh 27607 

Karen Stacy Popovich (OPH), 3320 Execu- 
tive Drive, Ste. Ill, Raleigh 27609 

Karen Denise Roane (OBG), 500 Benson Road, 
Gamer 27529 



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WESTERN NORTH CAROLINA: BC/BE internist to join 
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Send CV to P.A. Sellers, MD, 705 6th Ave. West, 
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Classified rates:ForNCMS members, $15forthefirst25 
words, 25 cents for each additional word; for non-mem- 
bers, $25 for the first 25 words, 25 cents for each addi- 
tional word. Mail to NC Medical Journal, Box 391 DUMC, 
Durham, NC27710,orfaxto:919/286-9219. Deadline for 
our next issue is February 10. 



NCMJ / January 1996, Volume 57 Number 1 55 



Aphorisms 
off the Month 

Daniel J. Sexton, MD, Editor 

''General Advice: Part I" 



Be wiser than other people if you can; but do not tell 
them so. 

— Lord Chesterfield 

Never hold discussions with the monkey when the 
organ grinder is in the room. 

— Winston Churchill 

If you have an important point to make, don't try to be 
subde or clever. Use a pile driver. Hit the point once. 
Then come back and hit it again. Then hit it a third 
time — a tremendous whack. 

— Winston Churchill 

Never trust a man who speaks well of everybody. 

— John Churton Collins 

If you would persuade, you must appeal to interest 
rather than intellect. 

— Benjamin Franklin 

A good time to keep yoiu^ mouth shut is when you are 
in deep water. 

— Sidney Gqff 

Never mind whom you praise, but be very careful who 
you blame. 

— Edmund Gosse 

Never take the advice of someone who has not had 
your kind of trouble. 

— Sidney J. Harris 

Don't tell your friends about your indigestion. "How 
are you," is a greeting, not a question. 

— Arthur Guiterman 



General Advice: Part II — in the March Journal. 
Fax aphorisms to Dr. Sexton at 919/684-8358 



Index to Advertisers 


Alpha Group Communications Co. 


26 


CompuSystems, Inc. 


back cover 


Crumpton Co., Inc. inside front cover 


The Doctors' Company 


7 


Duke Continuing Medical Education 


39 


Healthcare Consulting Group 


2 


Interim Physicians 


39 


MAG Mutual Insurance Co. 


13 


Medical BilUng Practice, Inc. 


41 


Medical Mutual Insurance Co. 


23 


Medical Protective Co. 


37 


Medstaff, Inc. 


6 


NCDEHNR Vaccine Program 


35 


Triad Radiographic Imaging 


11 


T. Rowe Price Investment Services, Inc. 




- 


1,35,39 


US Air Force inside back cover 


US Air Force Reserve 


17 



56 NCMJ / January 1996, Volume 57 Number 1 




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• No office overhead 
Dedicated, profession- 
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Examine your future in 
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For example, it might show how 
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800 installations in North and South 
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It might briiig home how features 
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It could clarify how critical "one- 
call" support can be in helping offices 
stay productive — how teleplione 
support staff, software and hardware 
engineers, teclrrdcians, trainers, and a 
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It niight demonstrate how on- 
going research and development 
brought innovations like the first 
integi'ated, direct electronic dairris „ 
transmission in a practice '" ' - "^ 

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Or it could validate the concept of ^ 
regional focus: By selling systems • f ,4s..;ss^*'- 
only in the Southeast, a computer 
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It could emphasize the flexibility 
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And it could illustrate the value of 
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The Official 
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Medical Society 

March/April 1996 

\/olume 57 
Number 2 



iJNorth Carolina 
Medical Journal 



For Doctors and their Patients 



The Anatomy of Managed Care 



uMiVERSITY OF ^iOSsH CAROLi;' 



^, 



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provided by your practice. The premium is 
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that care. You pay for only the coverage you 
use or need, instead of paying a flat annual fee. 
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NORTH CAROLINA 
MEDICAL JOURNAL 

For Doctors and their Patients 



EDITOR 

Francis A. NeelcHi, MD 

DEPUTY EDITOR 

Edward C. Halpcrin, MD 

CONSULTING EDITOR 

Eugene A. Stead. Jr., MD 

ASSOCIATE EDITORS 

Eben Alexander, Jr., MD 

Winston -Salem 
William B. Blythe, MD 

Chapel Hill 
F. Maxton Mauney, Jr., MD 

AsheviUe 
James P. Weaver, MD 

Durfiam 

MANAGING EDITOR 

Jeanne C. Yohn 

Durham 
919/286-6410 
fax: 919/286-9219 

BUSINESS MANAGER 

Donald R. WaU 



SECTION EDITORS 

Eugene W. Linfors, MD 
Daniel J. Sexion, MD 

EDITORIAL BOARD 
CHAIR 

Margaret N. Harker, MD 
Morchcad City 

MEMBERS 

Jack Hughes, MD 

Durham 
Patrick D. Kenan. MD 

Durham 
Assad Meymandi, MD 

Raleigh 
William G. Porter, MD 

Charlotte 
MaryJ. Raab, MD 

Greenville 
C. Stewart Rogers, MD 

Greenboro 
J. Dale Simmons, MD 

Raleigh 
Thomas G. Stovall, MD 

Winstffli- Salem 



March/April 1996, Volume 57, Number 2 

Published bimonthly as the official organ of the 

North Carolina Medical Society (ISSN 0029-2559), 

222 N. Person St., P.O. Box 27167, Raleigh, NC 2761 1-7167 

The Society is not to be considered as endorsing the views and opinions advanced by authors of 
papers delivered at the Annual Meeting or published in the official publication of the Society. — 
Constitution and Bylaws of the North Carolina Medical Society. Chap. IV. Section 3, pg. 4. 



NORTH CAROLINA MEDICAL JOURNAL 

E:diU)rial ofrice: Box 3910, Duke University Medical Center, Durham, NC 27710, (phone: 
919/286-6410, fax: 919/286-9219, e-maii: yohn0001@mcduke.edu), is owned and published 
by the North Carolina Medical Society under the direction of its Editorial Board. Copyright© 
1996 North Carolina Medical Society. Address manuscripts and communications regarding 
editorial matters, subscription rates, etc., to the Managing Editor at the Durham address listed 
above. (Use the following address for overnight and express mail to the editorial ofice only: 
2200 W. Main St., Suite B-210, Room 12, Durham, NC 27705.) Listed in Index Medicus. All 
advertisements are acc^ted subject to the approval of the Editorial Board of the North Carolina 
Medical Journal. The appearance of an advertisement in this publication does not constitute any 
endorsement of the subject or claims of the advertisement. 

Advertising representative: 

Don French. 318 Tweed Circle, Box 2093. Cary. NC 2751 1. 919/467-8515. fax: 919/467-8071 
Printing: The Ovid BeU Press. Inc.. 1201 -05 Bluff St.. Fulton, MO 65251, 800/835-8919 

Annual subscription (6 yourru/ issues): $20 (plus 6% sales ux = $21.20). Single copies: $3.50 
regular issues, $5 special issues. Roster $55 (plus 6% sales tax). Second-class postage paid at 
Raleigh NC 27601 , and at additional mailing offices. 

POSTMASTER: SEND ADDRESS CHANGES TO THE NORTH CAROLP^A 
MEDICAL SOCIETY, 222 N. PERSON ST^ P.O. Box 27167, RALEIGH, NC 276117167. 






,«*•' 



t»e 



Paving 

the 

way 

to 

Managed 

Care! 



NCPCN has a membership category for you! 

Categories include: 

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□ Residency training programs/AHEC programs 

□ Hospital/corporately owned primary care networks 

Join today! 

For membership information write, call or fax. 

NCPCN • PO Box 1&46a Raleigh, NC 27619 

919/510-0209 • 1-600/929-0209 (in NC) • 919/ 75)2-5976 (Fax) 



58 



NCMJ March/April 1996, Volume 57 Number 2 




"It's a good feeling having 
someone in my court." 

"Getting squeezed from both ends isn't 
pleasant. Losing sleep over professional 
liabilities isn't why I studied to be a medical 
professional. When questions 
of accountability arise, it 
seems everyone has their 
representative except 
the doctors. 

Medical Mutual has 
always been there. 
Even when the 
others pulled out. That 
means a lot. First, and foremost, 
it means that 1 can concentrate 
on my patients needs instead 
of worrying about liability 
insurance. Medical Mutual is 
in my court. Always has 
been. That's a good feeling." 



Medical Mutual 



Medical Mutual Insurance Company 
of North Carolina 

4505 Falls of the Neuse Road 

PO Box 98028 

Raleigh, NC 27624-8028 

Tel: (919)872-7117 

(800)662-7917 

Fax: (919) 878-7550 



Instructions for Authors 



The North Carolina Medical Journal is a medium for 
communication with and by members of the medical com- 
munity of this state. 1\\& Journal publishes six times a year: 
in January, March, May, July, September, and November. 
The Journal will consider for publication articles relat- 
ing to and illuminating medical science, practice, and his- 
tory; editorials and opinion pieces; letters; personal ac- 
counts; poetry and whimsical musings; and photographs and 
drawings. Papers that relate to the present, past, or future 
practice of the health professions in North Carolina are 
especially pertinent, but manuscripts reflecting other per- 
spectives or topics are welcomed . Prospective authors should 
feel free to discuss potential articles with the editors. 



Manuscript Preparation 

Prepare papers according to the "Uniform Requirements for 
Manuscripts Submitted to Biomedical Journals" (N Engl J 
Med 1991;324:424-8) with the following exceptions: 1) no 
abstract is needed; 2) no running title is needed; and 3) report 
measurements in metric units; use of the International Sys- 
tem of Units (SI) is optional. 

Submit a cover letter and either a 3 1/2-inch hard disk or 
5 1/4-inch floppy computer disk that contains the text written 
in MS DOS- or Macintosh-compatible format, and at least 
one hard copy of the text. Double space text with one-inch 
margins. Please do not "format" the text (e.g. no variations 
in type size, no bold face, no italics, no embedded endnotes). 

Submit illustrations, in duplicate, in the form of high- 
quality color 35mm slides or 5-by-7-inch or 8-by- 10-inch 
glossy photographs, or as black-and-white glossy prints (5- 
by-7-inch or 8-by- 10-inch). Label all illustrations with 
author's name, number them sequentially according to their 
position in the text, and indicate the orientation of the 
images, if necessary. Do not write directly on the backs of 
prints. This can damage them. If figures require printing in 
four-color process, the author may be asked to pay printing 
fees or a portion thereof. 

Type figure legends, double-spaced, on a separate sheet 
of paper. Tables should be typed, double-spaced, one to a 
single sheet of paper. All tables must have titles and consecu- 
tive Arabic numbers. Include tables, graphs, or charts on 
disk, if possible. 

Keep references to a minim urn (preferably no more than 



15), retaining those that document important points. The 
"Uniform Requirements" cited above contain reference for- 
mat. We customarily list the first three authors for "et al"- 
type references. Authors are responsible for the accuracy 
and pertinence of all citations. 

Avoid abbreviations entirely if possible; keep them to a 
minimum if not. When used, completely define abbreviations 
at the first point of usage in the text. 



Manuscript Review and Editing 

A medically qualified editor reads all manuscripts and, in 
most instances, sends them out for further review by one or 
more other members of the North Carolina Medical Society. 
Authors' cover letters must include a line that states that 
their submitted manuscripts are not under considerationfor 
publication elsewhere. Decisions to publish or not are made 
by the editors, advised by the peer reviewers. 

We encourage a relatively informal writing style since 
wc believe this improves communication. Imagine yourself 
talking with your unseen audience — as long as this doesn't 
lead you to scientific or linguistic inaccuracy. Be brief, clear, 
simple, and precise. 

We edit accepted manuscripts for clarity, style, and 
conciseness. Except for letters, authors receive a copy of the 
edited manuscript for their review and approval before 
publication. Manuscripts not accepted will not be returned. 

Authors retain copyright to articles published in the 
North Carolina Medical Journal, but the North Carolina 
Medical Society copyrights the contents of each entire issue. 
Requests for permission to reprint all or any part of a 
published article must be submitted in writing to the address 
below and negotiated with the author and editor jointly. 
Reprinted material must carry a credit line identifying that it 
appeared in the North Carolina Medical Journal. 



Submissions 

Address manuscripts and all other correspondence to: 
Editor, North Carolina Medicaljournal 
Box 3910, DUMC, Durham, NC 27710 
Telephone 9191286-6410 
Fax 919/286-9219 



60 



NCMJ MarchJ April 1996, Volume 57 Number 2 



orth Carolina Medical Journal 

FOR DOCTORS AND THEIR PATIENTS 

March/April 1996, Volume 57, Number 2 

Cover: Durham artist V. CuUum Rogers satirizes Rembrandt's "The Anatomy Lesson" for this month's segment on managed care. 



FROM THE GUEST EDITOR 

68 Managed Care: Hasn't Medical Journalism Beaten This Dead Horse Enough? 



Edward C. Halperin, MD 



THE ANATOMY OF MANAGED CARE 

70 The Shifting Horizon of Medical Practice in North Carolina 

74 Free Trade in Medicine: New Challenges for the Profession 

78 Medicine's Opportunities Under Managed Care 

80 Can We Serve Two Masters? The Ethics of Managed Care Practice 

84 The Future of Oncology Under Managed Care 



Robert W. Seligson, MBA, CAE 

Kenneth De Ville. PhD, JD 

Robert H. Bilbro, MD. FACP 

Anonymous 

Jeffrey C. Acker, MD 



CLINICAL COMMUNICATION 

92 Behind the Surgery Doors: A Look at What English General Practitioners Do 
98 The Doctor-Patient Relationship: Behavioral Aspects of an Unequal Partnership 



Francis A. Neelon, MD 
Gertrude Blanck, PhD 



FIRST-PERSON PHYSICIAN 

102 An Open Letter to My GrandchUdren 
104 HIV Myopia 



Thad B. Wester, MD 

J. Trig Brown, MD, MPH 



PHYSICIANS' ROUNDTABLES 

106 Anesthesia for Neonatal Circumcision: Is It State of the Art? 

R. Meade Christian, Jr., MD, Caryn Hertz, MD, William A. Nebel, MD, and Scott R. Schulman, MD, FAAP 
108 Should Abortion Training Be a Requirement of Obstetrics and Gynecology Residencies? 

Watson A. Bowes, Jr., MD, Takey Crist, MD, Edward C. Halperin, MD, and Charles B. Hammond, MD 

MEDICAL EDUCATION 

112 Resident Knowledge of Designations for Medically Underserved Areas 

Deirdre C. Lynch, RhD, Theodore W. Whitley, PhD, Maria A. Clay, PhD, and Thomas G. Irons, MD 

MEDICAL JARGONESE 

115 The Gold Standard Eben Alexander, Jr., MD 



87 



HEALTH WATCH 

Child Safety and Accident Prevention: Age- Appropriate Interventions 



C. Tate Holbrook, HI, MD, FAAP 



BULLETIN BOARD 

60 Instructions to Authors 116 

62 Letters to the Editor 118 

100 Change-of-address form 119 

113 Carolina Physician's Bookshelf 120 

114 In Memoriam: Dr. Jay M. Arena, Ms. Jane K. Whalen 120 



CME Calendar 
Subscription Form 
Classified Advertisements 
Aphorisms of the Month 
Index to Advertisers 



NCMJ March/April 1996, Volume 57 Number 2 



61 



Letters to the Editor 



i& 



Favorite Issue 

To the Editor: 

I would like to compliment and congratulate Dr. Neelon on 
the December 1995 issue of the North Carolina Medical 
Journal. I have been reading the Journal since I came to North 
Carolina four years ago — this was by far the best issue in that 
time period. Keep up the good work. 

Robert Rothbart, MD 

520 N. Elam Ave. 

Greensboro, NC 27403 

An Unsettled "House of Medicine" 
To the Editor: 

Dr. Frank Neelon's editorial, "The Fall of the House of 
Medicine?" (NC Med J 1995;56:600-1), was a magnificent 
piece of writing: sad, poignant, and true. Our profession and our 
Medical Society are in danger of becoming labor unions and 
trade associations. Dr. Neelon's editorial said much more 
eloquently what I tried to say in my inaugural remarks as 
Society president (see December Bulletin). Keep up the fight. 

H. David Bruton, MD, President 

North Carolina Medical Society 

195 W. lUinois Ave. 

Southern Pines, NC 28387 

To the Editor- 
In Dr. Neelon's lamentation, "The Fall of the House of 
Medicine?" he blames, among other despicable miscreants, 
managed care organizations for the "cajoling, coercing, and co- 
opting" of doctors and medical care in general. 

Those of us in administrative medicine would beg to differ 
with his reference to us as a "narrow bunch of business-oriented 
newspeakers." The Raleigh News & Observer refers to us as 
"faceless bureaucrats;" I'm not sure which I prefer. 

Frankly, I take pride in the care and compassion that enter 
into the decisions I make to improve the health care of the nearly 
quarter-million members of my managed care organization. 
The other medical directors in my organization (all of us are 
board-certified and North Carolina-licensed) use their clinical 
knowledge and compassion daily, even though none of us have 
the regular privilege of the bedside encounter. We readily 
acknowledge this fact. 

But, without managed care, would the variability in the 
occurrence of certain surgical procedures across the country 
every have been studied? (As a result, we know the Southeast 



has the dubious distinction of leading the nation in hysterec- 
tomy rates — I knew we were the stone belt but the fibroid belt 
as well?) Without managed care, would health insurance premi- 
ums be at least leveling off, and even declining in certain cases, 
including those in our state? Without managed care, would an 
organization like the National Committee for Quality Assur- 
ance exist? This group has established 70 standards against 
which it performs a rigorous assessment of managed care 
entities, exploring how well a managed care plan addresses 
member complaints and grievances; works with physicians to 
improve preventive health services; works with physicians to 
assure adequate medical record documentation; works within 
the managed care organization itself to promote a continuous 
quality improvement approach to service issues; and under- 
scores the imjrortance of appropriate and sensible credentialing 
policies and procedures. 

Also in the December issue was an article of considerable 
compassion from a physician who felt comfortable enough, and 
close enough to the family of a deceased patient, that he visited 
the patient's family at the funeral home ("Final Appointment," 
NC Med J 1995;56:614). Did anyone notice that he is a 
physician who works for the largest managed care company in 
the country? 

Robert T. Harris, MD, FACP 

Senior Vice President, Medical Management 

Healthsource North Carolina, Inc. 

4000 Aerial Center Parkway 

MorrisviUe, NC 27560 

To the Editor: 

After reading and re-reading Dr. Neelon's December edi- 
torial, I am still amazed by his perceptions and ability to write 

so well about the state of our profession. As Editorial Board 
chair, it has been a pleasure for the heart and mind to work with 
him and the Journal folks. I think the Medical Society should 
print up Dr. Neelon's words of wisdom as a pocket prayer for 
all members. 

Margaret N. Harker, MD 

Chair, Journal Editorial Board 

P.O. Box 897 

Morehead City, NC 28557 



Continued on page 64 



62 



NCMJ March/ April 1996, Volume 57 Number 2 



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Letters to the Editor 

continued from page 62 



To the Editor: 

I read Dr. Neelon's essay 'The Fall of the House of 
Medicine?" with great interest and respect. If our profession is 
indeed to survive as a profession, it will be through such 
eloquent efforts as Dr. Neelon's. The choice is ours: Do we 
remain physicians who practice the science and art of medicine, 
or do we allow current market fads to coerce us into becoming 
"technical health care providers?" 

I am saddened that the Journal has gone to a bimonthly 
publication schedule; since I moved to North Carolina five 
years ago, 1 have looked forward to each and every monthly 
issue. In an era of cost savings (and comer-cutting), \he Journal 
is an oasis, a rarity nowadays: a journal with a conversational 
style, authored, produced, and read by North Carolina physi- 
cians. As we are all buffeted by the winds of economic change, 
as we all lament the loss of the physician's control in the 
delivery of health care, we can look to the philosophy of Dr. 
Neelon and the Journal as a seed for the future, a way of 
regaining what we have lost: medicine with a human face. 

Gregory J. Davis, MD, Assistant Professor 

Department of Pathology 

Bowman Gray School of Medicine 

Medical Examiner, Forsyth County 

Winston-Salem, NC 27157-1072 

"Consultation" Critiques 
To the Editor: 

"Consultation at Twilight" (NC Med J 1995;56:608-10), 
struck a resounding chord. Each paragraph graphically brought 
to mind the plight that physicians find themselves in today. 
After practicing medicine for almost 40 years, I also began to 
suffer the problems expounded in Dr. Pisetsky's piece. 

In my own heart, I can't help but feel the helplessness and 
frustration expressed by the protagonist, Dr. Morgan. We 
should be able to justify all facets of our treatment of patients. 
To lower the practice of medicine to a set of guidelines set by 
an insurance company is demeaning and is leading to the "Fall 
of the House of Medicine" [see December issue, pgs. 600-1]. 

Unfortunately, physicians are individualists and don't act 
very well collectively. I'm afraid that this is one of the reasons 
why the House of Medicine is in its current state of disrepair. 

My hat is off to Dr. Pisetsky and the other December 
contributors for a meaningful set of articles. 

Bruce K. Willitts, MD 

2206 Gulf Shore Blvd., NG-2 

Naples, FL 33940-4615 

To the Editor: 

"Consultation at Twilight" is a provocative piece. My 
emotions on reading it are somewhat mixed. Perhaps it's 
because I am a 48-year-old dean with an MBA, just the type of 
character that drove Dr. Morgan to call it quits. I also have 



mixed emotions about the metaphor of King Arthur and his 
knights. I remember some of the dark side of that myth — the 
pompous, patriarchal professor who countenanced the virtual 
slave labor of indentured interns. I also know too many doctors 
who handle too many cases by doing too many tests. 

Perhaps my greatest ambivalence is about Dr. Morgan 
himself. He is a classic physician — with both the good and bad 
elements of that character. He cares for his patients and his 
profession. However, he also believes that he alone knows what 
should be done, he belittles those who question his judgment, 
and he has no evidence that his way is better. No wonder he 
wants to keep things the way they were. Those ways allowed 
him to determine what was right, to not be questioned about his 
decisions, and to make money in the process. 

I hope that Dr. Pisetsky is not thinking of "doing a Mor- 
gan." There are many rewards left in medicine. There are even 
opportunities for improving medical care and outcomes by 
building on just the changes that have driven Dr. Morgan away. 
Robert F. Meenan, MD, MPH, MBA, Director 
Boston University School of Public Health 
Boston, MA 021 18-2394 

To the Editor: 

I was saddened by the article "Consultation at Twilight" 
that appeared in the December 7our/ia/. I was also confused. Is 
this a work of fiction, or has Dr. Pisetsky retired? 

In any event, the tragedy in this article, whether true or 
pretend, is at least twofold. One is the excessive intrusion of 
non-physicians who fail to understand medicine as an art where 
the exception is at least as common as the rule. The second 
tragedy, however, was the unprofessional and boorish way in 
which a full professor of medicine behaved when faced with a 
bureaucratic antagonist. Surely we can expect more from all of 
us if we wish to remain professionals. 

Jack R. Page, MD, FACEP, MBA, Chief Medical Officer 

Coastal Physician Services, Inc. 

3708 Mayfair St., Suite 301 

Durham, NC 27707 

From the Editor: 

Dr. Pisetsky's piece was fictional; he is a F*rofessor of 
Medicine practicing rheumatology and immunology at Duke. 

To the Editor: 

"Consultation at Twilight" is splendid. I urge Dr. Pisetsky 
to submit it to the other state medical journals and JAMA. I 
intend to obtain 24 reprints and will make sure that each one 
reaches an infiu-ential person at the American Association of 
Medical Colleges, where I sit on the Executive Council. 

In his sidebar. Dr. Porter had it right: "[this story] illumi- 
nates the modem doctor's dilemma more vividly than any of the 
hundreds of articles and editorials on the subject" 
Arthur J. Prange, Jr., MD, Boshamer Professor of Psychiatry 
CB# 7160, UNC School of Medicine 
Chapel Hill, NC 27599-7160 



64 



NCMJ MarchJ April 1996. Volume 57 Number 2 



To the Editor: 

There is a challenge in medicine today, and that challenge 
is to become the ultimate patient advocate and guardian. 

That said, I have a few comments in response to "Consul- 
tation at Twilight," in which a retiring physician deals with a 
utilization reviewer denying payment for needed services. 
Businesspeople that hold the patients' money have a responsi- 
bility to use it on their behalf wisely, and certainly utilization 
review is a reasonable thing. When a company is clearly not 
thinking of the patient — and denies reasonable claims outright, 
or places bureaucratic roadblocks in the way of payment for 
legitimate services — it is our responsibility to expose them for 
what they are: businesspeople interested in making a dollar at 
someone else's expense. 

I have been in Dr. Morgan's position. Rather than getting 
mad however, I have a very simple solution. I tell utilization 
reviewers that any conversations should be recorded with 
instructions that the recording be turned over to the patient. It's 
amazing how those on the other end of the line suddenly become 
patient advocates, instead of dollar advocates. 

Edward S. Brezina, Jr., MD 

2101 Chelsea Drive 

Wilson, NC 27893 

Interpreting Cancer Statistics 
To the Editor: 

I support Dr. Jeffrey Wong's point of view on prostate 
cancer screening and appreciate his article in the January/ 
February yourna/ (NC Med J 1996;57:47-50). However, two of 
his statistics seem incorrect or at least inexplicable to me. It 
would be extraordinary, to say the least, if the mortality from 
prostate cancer had indeed fallen by 38% (from 65,000 to 
40,4(X)) in two years! What conceivable mechanism could be 
responsible? Actually, I find an estimated death rate of 35,(XX) 
(not 65,000) in the reference Dr. Wong cited for 1993. It is 
important for Dr. Wong to recognize this error in his future 
arguments because, given the uncertainties about treatment 
benefit, the notion that there has been a recent decline in 
mortality will be used by advocates to justify the current 
iatroepidemic of PSA screening and prostatectomy. 

The other figure I question is on page 48: "...only about 
one of every 380 men with histologic evidence of prostate 
cancer actually dies of the disease." If 3 % of men die of prostate 
cancer, that would mean that 1 140% of men must develop 
histologic evidence. Otherwise, I fully agree with Dr. Wong's 
thesis and found his article well-done. 

C. Stewart Rogers, MD 
Internal Medicine Training Program 

The Moses H. Cone Memorial Hospital, 1200 N. Elm St. 

Greensboro, NC 27401-1020 

Dr. Wong responds: 

I am pleased that Dr. Rogers supports my point of view on 
prostate cancer screening and I welcome the opportunity to 
clarify his questions. 



Dr. Rogers is absolute correct; the figure of deaths from 
prostate cancer inl993is35 ,(XX), not 65 ,(XX) as was m istakenly 
published.' What is extraordinary is that while the rate of new 
cases of prostate cancer has increased by ahnost 80% in that 
time, the rate of prostate cancer mortality has risen only 15%! 
There are many potential explanations why the rale of prostate 
cancer death is increasing at a considerably slower rate than its 
incidence, though none can actually be proven by these statis- 
tics alone. 

Dr. Rogers also makes a good point with the second figure 
in question. This refers to the often benign nature of localized 
prostate cancer in many patients. In 1988, Chodak and col- 
leagues,^ observed that a very large number of men with 
histologic evidence of prostate cancer actually died from some 
other cause. Using the figures from their study, they estimated 
that only one in 380 men with histologic evidence of prostate 
cancer would actually die of his disease. Dr. Rogers is correct 
in stating that roughly 3% of men die of prostate cancer. The 
discrepancy between these two sets of figures is probably best 
explained by the small size of Dr. Chodak's sample and by the 
statistics available for his use in 1988. 

Jeffrey G. Wong, MD, Assistant Professor 

Division of General Internal Medicine 

Box 3375, Duke University Medical Center 

Durham, NC 27710 

References 

1 Boring CC, Squires TS, Tong T. Cancer statistics, 1993. CA 
1993;43:7-26. 

2 Chodak GW, Keller P, Schoenberg H. Routine screening for pros- 
tate cancer using digital rectal examination. Prog Clin Biol Res 
1988;269:87-98. 

Article Timely for Physician 
To the Editor: 

I think Dr. Jeffrey Wong's articles in the Journal on 
preventive medicine and screening for disease have been excel- 
lent. As a 44-year-old male, I found his article on screening for 
prostate cancer in the January/February issue (NC Med J 
1996;57:47-50) especially germane. It answered several ques- 
tions that I had myself, and that my wife and I have lalkedabout, 
in terms of screening. 

In an era in which we are trying to control cost, and yet the 
public always seems to want us to do everything. Dr. Wong's 
articles really do address all of the issues very pertinendy. 

William J. Mallon, MD 

Triangle Orthopaedic Associates, PA 

2609 N. Duke St. 

Durham, NC 27704 

Reimbursement Clariflcation 
To the Editor: 

Dr. Gary O. Bean's letter to the editor in the December 
issue ("Planning the Future of Primary Care in NC," NC Med 
J 1995;56:597) demands a correction. 



NCMJ March/April 1996, Volume 57 Number 2 



65 



There is a glaring error in Dr. Bean ' s third point concerning 
Medicare reimbursement. Primary physicians and sub-special- 
ists are not reimbursed on different scales for performing the 
same procedures. This is not allowed by statute and is certainly 
not the case. 

I hope this clears up this misrepresentation of the facts. 

Andrew R. Price, MD, Medical Director 

CIGNA Medicare Administration 

Suite 240, One Triad Center 

7736 McCloud Road 

Greensboro, NC 27409 

Dr. Prichard and the Journal 
To the Editor: 

Thank you for publishing the unbutes to Dr. Robert Prichard, 
iormcr Journal editor and one of the outstanding faculty mem- 
bers at the Bowman Gray School of Medicine ("Farewells to a 
Friend," NC Med J 1995;56:530-2). He inspired me when I was 
a medical student there, and his leadership and ability lo inspire 
continued during the NC Medical Society's annual meeting in 
Pinehurst in the late 1970s, where I served as a first-year 
delegate. 

A topic on the meeting's agenda was whether or not to 
continue publishing this very journal. Budget problems had 
caused serious sentiment to discontinue the journal altogether. 
Intense debate had taken place that day between the leadership 
and the floor of the session, and opinion appeared to be about 
evenly divided. Dr. Prichard asked to speak and very eloquently 
challenged everyone there to decide whether or not what North 
Carolina physicians were doing was very important or not. The 
question he posed to the voters was if they thought what they 
were doing was important, then it was just as important to 
record their work for the benefit of others. 

Dr. Prichard further reasoned that if what wc were doing 
was not important, then we should discontinue ihc Journal. He 
felt like our work was indeed worthwhile, and he strongly urged 
us to cast our votes in favor of continuing it A brief silence 
followed his remarks. The vote was nearly or totally unani- 
mous, as I recall. 

I remember Dr. Wchard every time I see an issue of the 
North Carolina Medical Journal. I feel that ihe Journal itself is 
a continuing tribute to him and that he may well have single- 
handedly insured its continued publication on that occasion. 

Raymond E. Joyner, MD 

Durham Urology Associates, PA 

4003 N. Roxboro Road 

Durham, NC 27704 

Violence: Identifying the Causes 
To the Editor: 

The article "Death Worship, Carolina Style" in the Janu- 
ary/February issue (NC Med J I996;57:22) is worthwhile, but 
in my opinion, fails to define the real cause of the problem. As 
Dr. Davis notes, alcohol and drugs, guns, speeding, etc., all 
contribute but are merely the vehicles used by irresponsible or 



unthinking individuals to commit violence. Perhaps we are all 
guilty. At how many medical social events is there an absence 
of alcohol? Very few. We politely call it social drinking. How 
many physicians have received speeding tickets, etc.? 

I take strong issue with calling the new concealed weapons 
law insanity. Adverse effects simply have not been documented 
in states that have the law on the books. Quite the contrary; there 
is evidence that the opposite is true, and for this reason, I support 
the bill's passage. 

We dance around the edge of the problem and see only the 
symptoms, not the causes. When mankind loses the constraint 
of the Holy Spirit and does only what seems right in his own 
sight, then disaster will occur. I submit that we, in our glorious 
new era of political correcmess, have done everything in our 
power to remove every vestige of religion from our public and 
private lives. Now we are left with seemingly insurmountable 
problems. Perhaps we should begin to identify the real cause of 
our lawlessness — and the means toward such will be relegated 
to the proper place. 

Norman R. Sloop, MD 

1112StatesvilleBlvd. 

Salisbury, NC 28144 

Dr. Davis responds: 

I agree that alcohol, drugs, guns, and speeding cars are the 
vehicles of aggression used by irresponsible and unthinking 
individuals. I concentrate on these vehicles, for as a practicing 
forensic pathologist, they are the ones with which I come into 
contact daily as part of my practice. The underlying ills that 
cause irresponsibility, aggression, and violence were beyond 
the scope of my essay. However, as I have alluded to previously 
in the Journal (NC Med J I995;56:328, 335), if more of our 
citizens adhered to the Judeo-Christian ethic of the Golden i 
Rule, I would have more time to teach and do research and 
would not have to spend so much time in the autopsy room. 

My opinion diverges widely from Dr. Sloop's in regard to 
the concealed-carry law. The law means more guns are circu- 
lating because many law-abiding citizens now have, and many 
are applying for, permits to carry firearms. The majority of 
gunshot deaths I investigate are not perpetrated by assailants 
upon victims they don't know. They are, rather, suicides and 
domestic homicides in which members of a household kill one 
another. Many are accidental deaths caused by the thoughtless 
manipulation of a firearm by untrained or undertrained indi- 
viduals. Gun enthusiasts cheer whenever a story circulates 
about a person defending him or herself with a firearm, yet the 
actual incidence of such an event is vanishingly rare, whereas 
the events I describe occur almost daily in our state. If any other 
"product" were associated with so many deaths, physicians and 
the public would be screaming for governmental controls. 

Gregory J. Davis, MD, Assistant Professor 

Department of Pathology 

Bowman Gray School of Medicine 

Medical Examiner, Forsyth County 

Winston-Salem, NC 27157 



66 



NCMJ March/April 1996. Volume 57 Number 2 



Permission Please 
To the Editor: 

I am writing an article on pasteurella pneumonia for a 
zoonotic pneumonia issue in Seminars of Respiratory Medi- 
cine. I would like to reproduce figures la-b used in Dr. Jeffrey 
Kopita's article "Cat Germs: Pleuropulmonary Pasteurella In- 
fection in an Old Man," (NC Med J 1993;54:308-11). 

Natalie C. Klein, MD, PhD, Associate Director 

Infectious Diseases Division 

Winthrop-University Hospital 

Mineola, NY 11501 

From the Editor: 

We aie happy to have Dr. Klein use the figures, and we're 
pleased that they will grace her article. 



ADHD with medication should be made only by a "qualified 
psychiatrist." Indeed, there arc a number of physicians who are 
qualified to evaluate and treat an individual who has been 
diagnosed with ADHD. The point I meant to make was that this 
physician should be knowledgeable about the various medica- 
tions (and medication combinations) as well as other co-morbid 
conditions that often exist in an individual diagnosed with 
ADHD. Many of these physicians have been my esteemed 
colleagues for years and I regret any misinformation I may have 
communicated in my article. 

Barbara Hollandsworth Smith, MD 

Child, Adolescent and Adult Psychiatrist 

Director, Child Psychiatry Associates 

806 Green Valley Road, Suite 309 

Greensboro, NC 27408 



Diagnosing and Treating ADHD 

To the Editor: 

I was pleased to see the excellent article on attention deficit 
hyperactivity disorder (ADHD) by Dr. Hollandsworth Smith in 
the January/February Journal (Health Watch, NC Med J 
19%;57:27-30). The information she presented was accurate 
and timely. The public has been plagued with too many articles 
with negative connotations about ADHD. 

My only concern was with the statement "The decision to 
treat a patient with ADHD should be made by a qualified 
psychiatrist. . . ." As a certified specialist in the field of adoles- 
cent medicine and as a physician working with two fellowship- 
trained developmental pediatricians, I feel that we are also 
eminently qualified to evaluate an individual for ADHD whether 
that person is a child, an adolescent, or a young adult. We can 
also identify other conditions that may exist along with ADHD 
and institute appropriate treatment whether that be medical, 
counseling, educational, or, as is most often the case, a combi- 
nation of these therapies. Physicians who specialize in adoles- 
cent medicine and in developmental pediatrics have extensive 
exposure during fellowship years to patients with learning and 
behavior problems. 

Unfortunately, many managed care groups in North Caro- 
lina fail to recognize that ADHD is a neurological, biologically- 
based process and not one that is emotionally-based. Managed 
care groups fail to recognize that although psychiatrists are 
indeed qualified to make such a diagnosis and treat patients with 
ADHD, other physicians through their specialty training are 
equally qualified to do so. 

Edwin G. Farrell, MD, FAAP 

Specialist in Adolescent Medicine 

Developmental Associates 

1915 Lendew St., Suite 102 

Greensboro, NC 27408 

Dr. Hollandsworth Smith responds: 

I am grateful to Dr. Farrell for alerting me to the error in my 
article on ADHD. It was an oversight on my part (due to hasty 
editing and my own ADHD) to indicate that the decision to treat 



Guidelines for Letters: All letters are subject to editing 
and abridgment. They must be typed, double-spaced, and 
no longer than 500 words. Longer letters are welcome, 
however, and may be submitted (on computer disk) as 
editorials. Send letters to: North Carolina Medical Journal, 
Box 3910, Duke University Medical Center, Durham, NC 
27710, fax: 919/286-9219. 




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NCMJ March/April 1996. Volume 57 Number 2 67 



FROM THE GUEST EDITOR 



Managed Care 

Hasn't Medical Journalism Beaten This Dead Horse Enough? 

Edward C. Halperin, MD 



One of the benefits of being a physician in the 1980s was that 
you couldn'thelpbutdevelop an excellent collection of plaintiff's 
lawyers jokes. For example: 

What's the difference between a catfish and a 

plaintiffs lawyer? 

One is a bottom-dwelling, scum-loving, garbage 

eater; the other is a fish. 
or the always reliable: 

What's the difference between a dead skunk in the 

road and a dead plaintiff s lawyer in the road? 

You'll almost always find skid marks before the 

corpse of the skunk. 
There is a particularly long joke which was stolen by Steven 
Spielberg and his gag writer for the movie Hook — but 1 heard 
the joke from colleagues in the clinic long before Robin 
Williams ever told it on the movie screen: 

Why is the National Institutes of Health in Bethesda 

recruiting plaintiff s lawyers? 

Because they're more plentiful than experimental 

rats, the researchers don't get as attached to them 

as they do to rats, and besides that, there are some 

things that even experimental rats won't do. 
In the 1 980s tort reform was the talk of the clinic, the operating 
theater locker room, and the medical society meeting. The 
proliferation of plaintiff's lawyer jokes followed the trend. In 
the 1990s we've acquired a new favorite topic and a new form 
of humor. It's a form that is replacing lawyers jokes whenever 
physicians gather — the managed care joke: 

Didyou hear about the managed care organization 

chiefexecutiveofficerwhodiedandwent to heaven? 

He got to the pearly gates and met Saint Peter. 

"I'm glad to see you," Saint Peter said, "You can 

come in. But don't get too comfortable. You ve only 

been approved for a three-day stay." 



or: 



How many psychiatrists does it take to change a 



Dr. Halperin is Jouma/ Deputy Editor and Professor and Vice 
Chair, Department of Radiation Oncology, Box 3085, Duke 
University Medical Center, Durham 27710. 



light bulb? Just one, but the bulb has to sincerely 
want to change. 

How many surgical sub-specialists does it take to 

change a light bulb? None, the nurse case manager 

says it can be done cheaper by a family physician. 

How many family physicians does it take to change 

a light bulb? None, the nurse case manager says 

you've run out of capitation money. Sit in the dark 

until next year. 

I've always thought that humor was the dark underbelly of a 

culture. Jokes tell you a lot about people's anxieties. Our best 

jokes have a special bite. This is why jokes were one of the few 

forms of political discourse in eastern Europe before the fall of 

Communism. 

The development of managed care jokes exposes the 
discomfort sweeping through medicine: a discomfort bom of a 
general fear of change, a more specific fear that medical prac- 
tice is becoming something different than what we expected, 
and aperceived threat to our incomes and lifestyles. You can tell 
that managed care jokes hit home when you tell them. The 
listener does more than just laugh. They have a knowing smile 
and a special tilt of the head when the joke hits home. 

What can the North Carolina Medical Journal say about 
the rise of managed care that hasn't been said already? Every 
medical journal that comes across my desk seems to have three 
articles on the subject. I've sat through more grand rounds and 
continuing education conferences on the subject than I can 
remember (and if I hear the phrase "new paradigm" one more 
time I ' m going to get ill). Hasn 't the subject been done to death? 
Your faithful editors think not. With this issue of the Jour- 
nal we inaugurate a series of papers, to appear over the next few 
issues, on how managed care looks to NC's health profession- 
als. We've invited a cross-section of individuals to look at the 
medical economic scene and share their views with us. We 
promise our readers some new twists on the world of managed 
care. We've solicited articles designed to give our readers a 
particular NC slant on the problem: individual, incisive, and 
sometimes quirky. We invite you to share in the conversation by 
reacting to our articles with a letter (or two) to the editor. And 
if you've heard any good jokes lately, pass them my way. □ 



68 



NCMJ March/April 1996, Volume 57 Number 2 




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THE ANATOMY OF MANAGED CARE 



The Shifting Horizon of 

iViedicai Practice in North Carolina 

Robert W. Seligson, MBA, CAE 



North Carolina is seeing unprecedented changes in the delivery 
of health care. The marketplace has responded rapidly by initi- 
ating reforms to address the utilization, payment, and cost of 
health care. I review here the current status of reform in NC and 
its impact on physicians, patients, and the practice of medicine. 



Patient-Consumer Role 

The health care consumer is the most important component of 
the system. Today's patients know more about the delivery, 
availability, and costs of health care than ever before. They 
demand that services be both state-of-the-art and economical. 
Patients expect state and federal governments to control the 
escalating costs of health care while maintaining continued, 
uninterrupted access to the services they have grown accus- 
tomed to receiving. Despite all this, most consumers do not 
understand the impact that changes in health care delivery will 
have on their personal and family health care. 

How much downsizing of the health care system will the 
American public accept? Will they put up with actual reduction 
of services? The public certainly accepts the fact of some excess 
capacity at present. They believe that savings can be achieved 
by eliminating a part or all of this excess, but they have little 
information about the level of reduction of services that health 
care reform will dictate, and litde appreciation of the fact that 
entrepreneurial health systems will direct any savings into 
higher levels of return to stockholders or executive managers 
rather than into improvements in the system. 

If public expectations are met and costs are constrained, 
then the public will become a major player demanding further 
changes in health care. But if there are major Umitations in 
service without offsetting advantages, then we can expect the 
public to witiidraw its support. These are the biggest unknowns 
facing health care system planners. Dealing with the trade-off 
between cost reduction and limitation of services provides a 

Mr. Seligson is Executive Vice President, North Carolina Medi- 
cal Society, 222 N. Person St., P.O. Box 271 67, Raleigh 2761 1 . 



great opportunity for physicians, who probably understand the 
health care consumer better than any other group. 

The emerging integrated health delivery system will evolve 
from a combination of first-generation (preferred provider 
organizations), second-generation (health maintenance organi- 
zations; capitated payments), and third-generation (full-risk 
assumption; risk conu-ol) schemes. At present, about 12.3% of 
North Carolina's population is enrolled in managed care.' We 
can anticipate that this figure will grow two- to three-fold 
during the next three years, fueled by insurers and the many 
"managed care entrepreneurs" that have entered the state's 
expanding managed care market. 



Physician-Hospital Integration 

Over 50% of the hospitals surveyed by the NC Hospital Asso- 
ciation reported that they either employed physicians, were part 
of a physician-hospital organization, operated a management 
services organization (MSO), or worked with a physician or- 
ganization in their community.^ This has led to an increased em- 
phasis on the development of longitudinal medical records, 
case management by treatment protocols, outcome measure- 
ments, and network accreditation. I believe these trends will 
continue. 

I define an integrated health system as one that links 
together patient, provider, and a financial/insurance entity in a 
collaborative network. This type of program emphasizes pri- 
mary and preventive care in order to minimize cost and discour- 
age overutilization. Integrated delivery systems depend on and 
therefore lead to the expansion and enhancement of informa- 
tional systems. Developments in health care in North Carolina 
so far fall short of a fully integrated delivery system, but local 
hospitals know that they need to become involved in, and have 
shown a desire to become a part of, an integrated network. 

Table 1 , next page, shows the ways in which physicians and 
hospitals can be organized and integrated. As the degree of 
integration increases, so does the need for negotiation by 
doctors and hospitals. This, in turn, determines the kinds of 



70 



NCMJ March/April 1996, Volume 57 Number 2 



Table 1. Extent of physician-hospital Integration 



Impact on Hospitalization 



i 

2 


HIj 
i 

Lo 


3h 

r 
w 


Economic 
integration 
with primary 
care groups; 
hospital-owned 
practices 


Physician- 
hospital 
organizations 
engaged in 
risk contracting 


Fully integrated 
systems 


1 

5 

a. 
w 

o 

£ 
■ 

c 
a 

u 
« 


Medical office 
buildings; sub- 
sidies; practice 
support 


Clinics without 
walls; MSOs, 
foundation 
models 


Merged clinics 
and hospitals 
(usually positioned 
for risk contracting) 


>> 

£ 

a. 


Solo practices; 
small groups 


Physician 
organizations; 
consolidation 
of groups 


Significant group 
practices (multi- 
specialty and single 
specialty 






1 nw ^ 




^ Uinh 











Physician integration 

Source: BBC Research and Consulting 

networks that have developed in various regions of North 
Carolina. All types and levels of integration can be found here, 
with regional variations related to influence of outside entities 
such as health maintenance organization (HMOs), which have 
spurred the development of complex and fully integrated sys- 
tems in metropolitan areas. All this means that physicians will 
be working more closely with hospital administrators and other 
health care administrators in the managed care process. They 
will have contractual relationships with networks, will be 
employed by networks, or may be part of a group that is 
economically aligned with a network. More physicians will 
work in large group practices rather than in traditional solo or 
partnership practices. Managed care systems will increase the 
use of non-physician health care providers (such as physician 
assistants and nurse practitioners) in order to provide access at 
lower cost. Treatment by case management or clinical protocol, 
outcome measurements, and network accreditation will be- 
come the rule rather than the exception. But whether physicians 
have major control or ownership of the integrated system or not, 
they will still have an intimate and important role. 

As a practical matter, managed care networks prefer to 
contract with large groups of providers, rather than small 
groups or individuals. This means that a group member(s) must 
be designated as negotiator, a task requiring skill in determining 
net worth of services, estimating risk, and other related matters. 
Some group members will be required to develop skills in data 
base management, data analysis, and quality control. These 
administrative skills are more closely related to the medical 
practice rather than the fiscal management of the system. 



In NC, health system reform will decrease 
inpatient days by more than half.' It is projected 
that many hospitals will merge or close within 
the next five to 10 years, and the hospital 
employees currently working to support inpa- 
tient care will have to be retrained. 

Table 2, next page, illustrates hospital bed 
utilization rates for North Carolina in 1994 and 
projects the rates anticipated under a fully inte- 
grated system. The current occupancy rate for 
hospitals in North Carolina is 56%. Under 
current national HMO utilization rates, occu- 
pancy of hcensed beds would decrease to 39%; 
under a fully managed integrated system, the 
occupancy rale would fall to about 20%. The 
number of patient-days (one patient in hospital 
for one day) per 1,000 population would de- 
crease from the current 690 to 486 to 248 in a 
fully integrated system; some plans in Califor- 
nia have already dropped to less than 200 days/ 
1 ,(X)0. Reduced occupancy rates will decrease 
employment and the availability of inpatient 
and outpatient hospital jobs. 

According to the AMA, in 1992 there were 
255 physicians per 100,000 population in the US. Between 
1975 and 1992, only minor changes in the distribution of 
physicians by specialty occurred. Physicians spent 54% of their 
direct patient care hours seeing patients in the office setting, and 
18% in hospital rounds. Patient visits per week have declined 
both in offices and in hospitals, but with state and national data 
indicating shorter lengths of hospital stay, the number of 
outpatients will increase. Hospitals are developing outpatient 
care facilities to help offset the loss of inpatient visits. 

On a national basis HMO enrollment increased from 37 
million in 1990, to more than 47 million in 1993, and an 
estimated 56 million in 1995." Managed care participation by 
all physician practices (solo or group) continues to expand. 
Currently, North Carolina ranks 38th among the states in the 
number of doctors affiliated with prepaid or managed care 
plans, but this will probably increase since North Carolina has 
the highest percentage of physicians working in group practice 
settings.' Of 13,200 non-federal physicians in North Carolina, 
8,1 16 work in group practices.' The trend toward more group 
practice in the state is expected to continue because economies 
of scale and other efficiencies realized by group practices will 
make it difficult for doctors to practice independently. 



Importance of Large "Block" Buyers: 
Medicare and Medicaid 

Nationally, only about 8% of the Medicare population has 
chosen managed care. In North CaroUna, managed care does 



NCMJ March/April 1996, Volume 57 Number 2 71 



not yet play a significant role in Medicare and 
Medicaid but can be expected to do so, given 
the emphasis Congress has placed on limiting 
the cost of Medicare. Block grants for Medi- 
care will place great pressure on North Caro- 
lina to control costs. In North Carolina, Medi- 
care accounts for 42% gross hospital patient 
revenue and Medicaid, 13%.' In the past 10 
years the Medicare population in North Caro- 
lina grew at an average rate of 24,502/year, 
from 752,160 enrollees in 1984-1985 to 
972,680 inl993- 1994.' 

In 1992 approximately 13% of the US 
population used Medicaid, and the federal gov- 
ernment financed 57% of the bill.*i"°' Medic- 
aid enrollees in North Carolina grew by 1 8% in 
1990-1992 and 13% in 1992-1993.''"" Sixty- 
nine percent of the eligible population aged 0- 
17 participated in Medicaid and 63% of the 
population aged 18-64;*'"^ a total of 658,000 
of 997,000 eligible North Carolinians (18% of the non-elderly 
population) participated in the Medicaid program during 1990- 
1992.8pi22 Yhe need to care for the uninsured, including the poor 
who do not qualify for Medicaid, will pressure North Carolina 
to find ways to increase availability of coverage while control- 
ling costs. 



HMO Penetration 

Table 3, at right, shows the number of North Carolinians 
enrolled in HMOs as of July 1995. The total represents 12% of 
the market.' With recent HMO growth, the total number of 
managed care enrollees may now be more than one million 
people. The Raleigh/Durham area has the highest percentage of 
HMO enrollees (26%), followed by GreensboroAVinston-Sa- 
lem(22%),Asheville(13%)andCharlotte(13%)(Table4,next 
page). The HMO penetration rate has increased dramatically 
since 1989 when the three licensed HMOs covered 266,199 
lives or 4% of the state's population. 

Although Congress debated health care reform in 1994, it 
chose not to act. So private market forces have begun to 
transform the country's medical system. Medical corporations 
that initiated aggressive marketing campaigns or pursued ac- 
quisitions or mergers have quickly become dominant players. 
Nationally, the money spent on mergers and acquisitions of 
hospitals, clinics, and doctor groups (including their patient 
lists, medical labs, and other patient care services) totals $280 
billion.' Rapid growth in membership, relatively slow growth 
in medical costs, and negotiated contracts heavily favoring 
insurance companies have given these companies financial re- 
serves and liquid assets of as much as 15%. Instead of being 
used for patient care, this surplus is being used to capitalize and 
expand the corporations' current market share. Undoubtedly, in 
a capital intensive market where competition is the driving 



Table 2. Hospitalization rate 


, NC vs. US 










1994 
data 


US HMO 
rate 


Integrated 
system* 


Licensed acute beds 
Staffed acute beds 




23,982 
20,653 


23,983 
20,653 


23,983 
20,653 


Population (millions) 
Hospital days/thousand 
Acute days (millions) 




7.1 
690 
4.9 


7.1 
486 
3.4 


7.1 

248* 

1.8* 


Occupancy 
licensed beds 




56% 


39% 


20%* 


staffed beds 




65% 


46% 


23%* 


'estimates 










Sources: NCHA Patient Data System, AHA Annual Survey and NCMS Statistical 
Extrapolated; Capitation 1: Tfie New American Medicine, The Advisory Board 
Company. 



Table 3. HMOs in North Carolina 




Organization 


Covered lives 


1. Blue Cross/Blue Stiield 


106,117 


2. CIGNA Health Plan 


83,144 


3. Healthsource of Northi Carolina 


127,421 


4. Kaiser Foundation Health) Plan 


126,881 


5. Maxicare of North Carolina 


17,102 


6. Partners National Health Plan 


91,850 


7. PHP, Inc. 


131,778 


8. Prudential Health Care 


48,683 


Total group enrollment 


756,152 


HMO enrollment 


601,830 


Point of service enrollment 


154,322 


Total population 


7,018,196 


Population under 65 


6,131,629 


Market share 


12% 


'Source: Carolina Managed Care 





force, these companies will continue to acquire and merge with 
others to expand their market base and profitability. 

The role for physicians in the turbulent health care market 
will depend on their ability to establish networks to negotiate 
with the integrated delivery systems, their ability to obtain 
proper capitalization, and the passage of legislation providing 
them with federal anti-trust relief to ensure the development of 
health plans that substantially benefit consumers. 



Entitlement Programs 

Even a Republican-controlled Congress (whose "Contract with 
America" advocates tax cuts, higher defense spending, and a 



72 



NCMJ March/April J 996, Volume 57 Number 2 



balanced budget) will find it hard to ignore the voters who are 
recipients of entitlement benefits. Entitlements account for 
54% of the federal budget and by 2004 this will reach 63%. The 
federal government spent $158 billion on Medicare in 1994; 
federal and state governments spent $146 billion on Medicaid. 
Social Security and other major entitlement programs have 
been politically "untouchable," but Medicare and Medicaid 
will be prime targets for future cuts — not in terms of program 
benefits, but in the form of arbitrary spending caps and other 
methods to control payments to physicians and other health care 
providers. 



Impact on Physicians 

The impact of health system reform and related market activi- 
ties on North Carolina physicians include the following: 

1. The percentage of North Carolina physicians affected by 
managed care will continue to increase dramatically. Physi- 
cians will have to adjust to health system reform initiatives 
(managed care, acquisitions, mergers, and other business 
ventures). 

2. The proportion of physicians in group practice will increase 
because of the need to remain profitable in a competitive 
environment. North Carolina already has the greatest per- 
centage of physicians in group practice and this figure will 
grow as solo practitioners struggle to operate efficiently 
under a multitude of managed care directives, government 
regulations, and other requirements. These will be more 
easily handled by group practices, which can benefit from 
economies of scale. 

3. Physicians' office staff will spend an increased amount of 
time dealing with third-party procedures and regulations. 

4. The financial condition of solo practitioners will deteriorate; 
those in group practices will fare better. 

5. A growing percentage of North Carolina physicians will 
prefer to participate in some type of integrated network. 

6. The trend toward capitated reimbursement of physicians 
will continue, but a greater financial risk lies in being 
"locked out" from participation in specific plans. The con- 
solidation of health care systems will have a profound effect 
on physicians who are not affiliated with a well-organized 
network. 



Table 4. HMO nfiarket share in NC 




City/region 


% share 


asof Jan 1995 


Asheville 




13% 


Charlotte 




13% 


Fayetteville 




7% 


Greensboro/Winston-Salem 




22% 


Hickory /Morganton* 




0.1% 


Raleigh/Durham 




26% 


Wilmington 




8% 


Non-metro 




2% 


North Carolina 




10% 


* January 1995 data combines Hickory Blue Cross Blue Shield 


enrollment with Asheville and Wilnnington enrollmentwith Fayette- 


ville. Source: Carolina Managed 


Care 





The Medical Society's Role 

The North Carolina Medical Society (NCMS) will continue to 
play a significant role in providing support and guidance to the 
physicians of North Carolina in these turbulent times. The 
NCMS will assist members with contract evaluation review, 
with forming physician-directed managed care networks, with 
resolving claim problems involving third-party payers, with 
developing guidelines on the "principles of managed care," and 
by sponsoring seminars to help educate physicians about man- 
aged care. The NCMS is currently negotiating the managed care 
rules proposed by the State Insurance Department The Medical 
Society is helping ensure that doctors play a role in developing 
the policy guidelines of managed care companies and that 
patients have access to understandable information about man- 
aged care plan coverage and limitations. The Society will seek 
legislation at the national and state levels to ensure that physi- 
cians have a "level playing field" in negotiation with managed 
care entities. 

The NCMS has long supported a pluralistic system of 
health care. No single strategy or plan will be appropriate for 
every area of the state. Physicians must learn more about 
managed care. They must take leadership roles, in careful, well- 
executed steps, to deal with the development of managed care 
in their communities. The services and expertise available from 
the NCMS can help them avoid decisions that will have nega- 
tive ramifications for their practices. □ 



References 

1 Carolina Managed Care. Nashville, TN: Harkey and Associates, 
Inc., September 1995, p 1.1. 

2 Physician Hospital Integration: Trends in North Carolina 1993- 
1995. Raleigh, NC: NC Hospital Association, December 1995, p 2. 

3 Integrated Delivery Systems: Report and Recommendations 1994. 
Raleigh, NC: North Carolina Hospital Association, 1994, p 4. 

4 The AMCRA Foundation, 1993-94 Managed Care.Overview 7,17. 
1994 HMO Performance Report 1 (Group Health Association of 
America, 1994). Managed Care Digest. Marion Merrell Dow, Inc., 
1993. 

5 Medical Groups in the US: A Survey of Practice Characteristics. 



Chicago, IL: American Medical Association, 1993, p 34. 

6 Managed Care: Report and Recommendations 1995. Raleigh, NC: 
North Carolina Hospital Association, October 1995, pp 7,8. 

7 Statistical Information Section, Baltimore, MD: Health Care Fi- 
nancing Administration, May 1995. 

8 WinterBottom C, Liska DW, Obermaier KM, et al. State-Level 
Databook on Health Care Access and Financing. Baltimore, MD: 
University Press of America, 1995, pp 109, 122, 124, 127. 

9 Lazarus A. The Effect of Mergers and Acquisitions on Behavioral 
Health Care. Medical Interface, January 1995, p 105. 



NCM J March/ April J 996, Volume 57 Number 2 



73 



THE ANATOMY OF MANAGED CARE 

Free Trade in Medicine 

New Challenges for the Profession 



Kenneth De Ville, PhD, JD 



What a difference two years makes. To many, the 1993-1994 
debate over health reform cast the shadow of Karl Marx over 
organized medicine. The fear of socialized medicine formed a 
subtext of the health reform discussions. Two years later, it is 
not Karl Marx that worries commentators, but Adam Smith. 
The free market is revolutionizing health care delivery in the 
United States. Hospitals, doctors, clinics, and insurance compa- 
nies are linking up to form "integrated," "managed" networks 
to finance care as well as deliver it. This astonishing and historic 
transformation has been driven by a belief that whoever moves 
fastest will control patients, money, and profits. 

It is true that much money can be made in health care, but 
a desire to control costs and the practice of medicine also fuels 
this revolution. Thirty years of increasing health care expendi- 
tures have led government and employers to demand some 
control over costs. Private insurers, the government, and man- 
aged care groups have responded with a mind-numbing array of 
cost-containment mechanisms, mostly by using physicians as 
"gatekeepers." Cost containment is now a basic underlying aim 
of any entity that delivers or finances care. 

These developments — the market-based organization of 
health care delivery and the advent of sophisticated cost con- 
tainment measures — raise two abstract questions with very real 
implications for policy makers, administrators, physicians, and 
patients: 1) Should we apply market ideology to the deUvery of 
health care? 2) Do new economic realities erode the traditional 
doctor-patient relationship? 



Is Market Ideology Appropriate 
for the Delivery of Health Care? 

Commentary in the New York Times has praised the advent of 
a genuine medical marketplace and confidently predicted that 
managed care will allow market forces to solve the problems of 
medicine.' According to this view, contemporary American 
medicine is a prototypical example of market failure. To repair 



VI « 



the accumulated damage, society needs to ensure that the health 
care sector is subject to the laws of economics. This is an 
increasingly common and recurring theme in current health 
policy literature. Some commentators celebrate free-maricet 
ideology, others accept it without comment or careful critique. 

On the other hand. Dr. Jerome Kassirer, editor-in-chief of 
the New England Journal of Medicine, has declared that the 
issue of "Whether health care should be subjected to the values 
of the marketplace is a fundamental question facing us today."^ 
Kassirer is right. Ideas matter. People use ideas to frame 
questions and to make decisions, and they are currently basing 
health care decisions on free-market ideology. Consequently, it 
is essential that we consciously and thoroughly review the 
implications of such an approach. 

Classic market ideology is an economic theory, a theory of 
human behavior, and a theory of organization. Its central 
assumption is that individuals are predictably self-interested. 
This self-interest is not bad, rather it is the "invisible hand that 
leads to efficiency in the market." Self-interest encourages 
consumers to negotiate for the lowest price and highest quality 
when purchasing goods and services. The self-interested desire 
to make money encourages the production of better goods and 
services, not necessarily because the producers are benevolent 
people (although they may be), but because they want to make 
money. Producers are encouraged to keep prices low by com- 
petition from other producers who vie for the money of consum- 
ers. Self-interest is seen as neither disruptive nor dangerous 
because consumers expect producers to maximize their profit, 
and producers expect consumers to bargain for the best goods 
and services at the lowest prices.' 

But that is not all that market forces do. The market ensures 
responsiveness to consumer desire without external regulation. 
The law of supply and demand results in provision of goods and 
services that society wants, in the quantities that it wants, at the 
price it is wilUng to pay, all without regulation. Self-interest 
also influences the distribution of labor by encouraging indi- 
viduals to do whatever work society is most wilUng to pay for. 



Dr. De Ville is Assistant Professor, Department of Medical Humanities, East Carolina University School of Medicine, Greenville 
27858-4354. This essay is based on talk presented at the Health Law Forum, Greenville, September 13, 1995. 



74 



NCMJ March/April 1996, Volume 57 Number 2 



A properly functioning market provides market discipline — 
disincentives to overuse and overproduction, f^ice sensitivity 
encourages individuals to spend their money on the things they 
value the highest.* 

Let us assume that all the good things that market ideology 
predicts will happen, do happen. It is a compelling and impor- 
tant description of how the ordinary world of goods and services 
works. But do market forces apply and accomplish the same 
things when applied to medical care? How is buying bagels or 
used cars like buying health care? Do patients, as consumers, 
act out of self-interest? Certainly. They try to get the best 
medical care for the least amount of money. Is it possible that 
patients might overuse medicine if there is no disincentive to 
overuse (that is, no market discipline)? Yes again. Patients who 
pay little out of pocket might be more likely to ask for care that 
they do not require. 

Do physicians and other health care providers act out of 
self-interest? Are they influenced by financial incentives and 
disincentives? Surely the desire to earn money motivates some 
physicians to work hard and excel, and to the extent that it leads 
to more competent physicians, it is beneficial. In addition, 
physicians are undoubtedly responding, at least in part, to 
market forces when they seek training in medical specialties 
that are highly reimbursed and shun those that are not. And, 
there is evidence that physicians sometimes provide excessive 
care when there is a financial incentive to do so.' 

In these respects the medical "market" has much in com- 
mon with the market for other goods and services, leading many 
commentators and pohcy makers to assume that this world- 
view is broadly true. Much about market theory is at least 
partially applicable to medicine, and market forces that are 
relevant to health care must be taken seriously. 

But many people continue to assert that medicine is in some 
way special' and not to be viewed as an ordinary market. The 
free-market model of bargaining requires and presupposes 
equal knowledge and equal distribution of power between the 
two bargainers. But there is a vastly unequal amount of knowl- 
edge between physician and patient. A layperson knows infi- 
nitely more about bagels, and used cars, and other goods and 
services than about medical care. In addition, the vulnerability 
of the patient and the inherent psychological impact of sickness 
make it difficult, even impossible, for patients to "bargain" 
fully as they might in a purely commercial transaction — or to 
refuse to participate if "negotiations" break down. Medical 
relationships are characterized by intrinsically unequal bar- 
gaining power, and without equal bargaining power, effi- 
ciency — the presumed by-product of ordinary market rela- 
tions — cannot materialize. 

Moreover, patients do not bargain in the ordinary sense of 
the market model. If they bargain at all, they do so not with 
physicians and nurses but with third-party payers, indemnity 
insurers, and managed care organizations. Medical profession- 
als, too, may bargain with third-party payers but the relation- 
ship is clearly not that envisioned by classical market theorists. 
In addition, medical need is quite different from the desires or 



wants that one encounters in other areas of the economy. Health 
care costs sometimes accrue rapidly and without warning. They 
are often not predictable in the manner of ordinary goods and 
services. Just as importantly, market reasoning presupposes a 
series of exchanges with the customer who, if dissatisfied, goes 
to a different provider the following day. This is a sensible 
description of the workings of the bagel market, but in medi- 
cine, patients who do not like the product delivered, may have 
no opportunity to switch to another provider the next day. Poor 
care may be irrevocable. It is not even clear that patients can 
distinguish good care from bad. A recent study found that very 
few patients could identify whether they had been injured as a 
result of their medical treatment.' 

In general, market advocates talk and act as if economic 
self-interest was the only thing that motivates individuals. 
Clearly self-interest and financial incentives and disincentives 
play some role in why individuals enter medicine and provide 
care, but many also have non-economic reasons, such as altru- 
ism and intellectual excitement. In addition, market ideologues 
have difficulty applying their theories to the delivery of care to 
the growing population of medically underserved, many of 
whom are children. Market analysis holds that individuals 
should get what they pay for, the benefits of their bargain. 
Individuals deserve what they can afford to purchase. This 
position may be a defensible to a degree, but it rests on the 
potentially incorrect assumption of justice in the initial distribu- 
tion of resources. It is important for the medical profession and 
the public to discern where market forces apply, and where they 
do not 



New Economic Realities and 
the Doctor-Patient Relationship 

Since the health care landscape is being transformed, it is 
important to determine whether new economic realities have a 
similar impact on the doctor-patient relationship. As mentioned 
earlier, virtually all current cost-containment strategies enlist 
physicians as "gatekeepers" of care. This makes sense in that 
the decisions and recommendations of front-line physicians 
account for 70%-80% of health care expenditures. Most man- 
agement and cost-containment techniques affect professional 
autonomy in some way. Professional autonomy is an important 
element of job satisfaction, but even more it is an admission that 
patient care is invariably a case-by-case endeavor. Autonomy 
is important from an ethical perspective because the delivery of 
health care is a moral enterprise whose ethos has been main- 
tained in part by physician autonomy. Capitalists understand- 
ably put profits first, but physicians have traditionally been 
expected to, and willingly have, put patients first. 

The traditional view holds that physicians have a duty to 
place their patients' interests above their own, above other 
patients' interests, above other duties. The doctor-patient rela- 
tionship is based on professional skill and loyalty, and patient, 
vulnerability and trust Crawshaw and his colleagues, in an 



NCMJ March/April 1996, Volume 57 Number 2 



75 



article titled "The Physician-Patient Covenant," offer an elo- 
quent articulation of the traditional notion of the professional 
ethos. They warn that "for-profit forces press the physician into 
the role of commercial agent to enhance the profitability of 
health care organizations" and insist uncategorically that phy- 
sicians must never be "gatec losers."* Other commentators, too, 
have worried that institutional arrangements may turn physi- 
cians into "double agents" and divert them from a patient- 
centered ethic' The North Carolina Medical Board announced 
last July that despite "the movement toward restructuring the 
delivery of health care. . . it is unethical for a physician to allow 
financial incentives or contractual ties of any kind to adversely 
affect his or her medical judgment."'" 

These warnings are a clear response to the current strate- 
gies that threaten to transform our traditional understanding of 
physicians' duty to their patients. It is true that physicians who 
practice within a managed care environment continue to have 
duties toward their individual patients, but they often have 
additional (and sometimes conflicting) responsibilities to the 
institution, to their colleagues, and to other patients in the plan. 
Will this new array of duties undermine their duty to individual 
patients? Consider what happens if a managed care or insurance 
contractor denies a particular kind of care that the treating 
physician considers indicated. Does a physician's duty to the 
patient require him or her to "game" the system — to mislead the 
third-party payer in order to get the care the patient requires? 
Some commentators argue no. They contend that physicians are 
not required to break economic rules to ensure that their patients 
get care; physicians should be advocates for their patients, but 
they are neither required nor entitled to commandeer economic 
resources that "belong" to neither patient or physician. Nor are 
they required to provide the same level of medical care to all 
patients." This line of reasoning, of course, runs counter to the 
ethos championed by Crawshaw et al, who state categorically 
that physicians are not to be "gateclosers," period. 

The nature of medical professionalism must ultimately be 
resolved by society, the profession, and in the hearts of indi- 
vidual physicians. In the meantime, it is possible to envision 
how traditional duties that may unfold if the economic and 
market (r)evolution continues its present course. Many of the 
physician's ethical and professional duties will remain un- 
changed by the new economic arrangements. Physicians will be 
expected to possess knowledge, skill, discipline, compassion, 
and courage. They will maintain their fiduciary duty toward 



patients, looking after their interests and not exploiting the 
relationship. Physicians have always had a duty to reveal to 
patients real or potential conflicts of interest, but some com- 
mentators suggest that physicians should now provide eco- 
nomic disclosure. Patients may want to know the nature of cost- 
containment measures, economic incentive schemes, and con- 
flicts that might influence the recommendations and actions of 
their physicians. Physicians may have a duty to refuse to 
participate in economic schemes that excessively and danger- 
ously Umit care.'^ For example, reimbursement contracts that 
do not contain stop-loss or profit-cap provisions might exces- 
sively compromise physician loyalty. Or, physicians might 
refuse to participate in any delivery plan that does not have an 
effective and fair appeals policy in place. Some observers even 
argue that physicians should not participate if their income is 
affected in any way by the nature and amount of the care that 
they recommend for patients. Physicians have played advocacy 
roles before, but they may now be faced with a broader duty to 
plead patients' cases inside the health care institution or plan. 

These potential new duties are natural outgrowths of the 
physician's responsibility to look after the interests of the 
patient, but they are not cost- free. A broader duty of advocacy, 
if taken seriously, may jeopardize the physician's income and 
ability to practice medicine if the organization is dissatisfied 
with nature of the advocacy. Explaining the intricate implica- 
tions of cost-containment mechanisms may create a huge 
administrative burden on physicians, confuse and worry pa- 
tients, and create liability risks. Such advocacy may, instead of 
engendering understanding, undermine the trust that is essen- 
tial for a successful therapeutic alliance. 

Once the physician-patient relationship has been altered, I 
am not certain that it can be reclaimed. Therefore, those who 
provide health care should consider two duties of heightened 
importance in what is rapidly becoming a medical marketplace: 
1) Managers, administrators, and physicians should nurture the 
development of an institutional and corporate ethos that is 
consistent with both profit-making and good medical care. As 
idealistic as this proposal sounds, there are corporations and 
institutions that are able to both do well and do good. 2) If the 
delivery system becomes incompatible with patient well-being, 
physicians, administrators, and other health professionals have 
a duty to work for social and political change. They who 
understand best the mechanics of the system are best situated to 
provide the vision for reform or regulation. □ 



References 

1 Krieger LM. How managed health care will allow market forces to solve 
the problems. New York Times, August 13, 1995:F 12. 

2 Kassirer JP. Managed care and the morality of the marketplace. N Engl J 
Med 1995;333:50-2. 

3 Heilbroner RL. The Worldly Philosophers. New York, NY: Simon and 
Schuster, 1964. pp 37-42. 

4 Epstein RA. Why is health care special? U Kansas LRev 1992;40:308-24. 

5 e.g. Wilensky GR, Rossiter LF. The relative importance of physician- 
induced demand in the demand for medical care. Health and Soc 
1983;61:252-77. 

6 Suhnasy D. What's so special about medicine? Theoretical Medicine 
1993; 14:27-42. 

7. Localio AR, Ljwthers AG, Brennan TA, et al. Relation between malprac- 



tice claims and adverse events due to negligence. N Engl J Med 
1991;325:245-51. 

8 Crawshaw R, Rogers DE, PeUigrino ED, et al. Patient-physician covenant 
JAMA 1995;273:1553. 

9 Angell M. The doctor as double agent. Kennedy Inst Ethics J 1993;3:279- 
86. 

1 North CaroHna Medical Board. Position statement on the physician-patient 

relationship, July 22, 1995. 

1 1 Morreim EH. Balancing Act: The New Medical Ethics of Medicine's New 

Economics. Washington, DC: Georgetown University Press, 1995, pp69- 
98. 

12 Rodwin MA. Medicine Money and Morals: Physicians' Conflicts of 

Interest. New York: Oxford University Press, 1993, pp 213-20, 253-5. 



76 



NCMJ March/April 1996, Volume 57 Number 2 




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THE ANATOMY OF MANAGED CARE 

Medicine's Opportunities 
Under i\1anaged Care 



Robert H. Bilbro, MD, FACP 



Managed care has disturbed many of North Carolina's physi- 
cians and surgeons. We long for those days when we had the 
tools to provide effective medical care, and patients had open- 
ended third-party payment for that care. Part of the problem 
today stems from the fact that most citizens, including physi- 
cians, have never experienced health care before the time of 
Blue Cross, Medicaid, and Medicare. Today's physicians do 
not get paid with garden produce or smoke-cured hams. They 
have office managers and sophisticated computers to handle 
claims filing and cash flow. 

The fee-for-service system produced generous revenues 
and practice growth but lacked checks and balances. The costs 
of health care escalated as a result of a confluence of factors: 1) 
logarithmic growth in technological capacity; 2) economic 
incentives to use such capacity; 3) minimization of patients' 
concern about cost since third parties paid the bills; and 4) 
threats of legal liability against providers. It takes no advanced 
degree in economics to recognize that such a constellation of 
factors will generate rapidly inflating costs. Application of 
some method of economic brakes was inevitable. 

The "good old days" (which became prevalent in NC 
during the 1960s) essentially gave the consumer a charge card 
and free run in a huge department store. Clerks were told to sell 
the consumer all he or she needed (indeed, all he or she wanted) 
and send the bill to a government agency or an insurance 
company. Consumers were delighted. They readily sought to 
get the best and the most, sometimes choosing more than they 
actually needed. It is no surprise that American ingenuity and 
marketing skills expanded the array of expensive products. To 
intensify the dynamics, legal liabilities severely penalized 
clerks when consumers did not get a "perfect" product. 

Again, it is no surprise that under this system governmental 
payers began to deplete their funds, and insurance companies 
levied 15%-50% annual increases in insurance premiums. A 
vicious spiral ensued. People were priced out of the health 

Dr. Bilbro is a partner, practicing internal medicine, at Raleigh 
Medical Group, PA, 3521 Haworth Drive, P.O. Box 18563, 
Raleigh 27619-8563, and chairs the Board of Directors of 
Healthsource, North Carolina. 



insurance market; the percentage of our population with no 
health insurance grew; large numbers of people with costly 
health problems could not even consider paying their bills; and 
cost shifting raised the premiums of those who paid. It became 
apparent to objective observers that the system was unwork- 
able. Corporate America, state and federal legislatures, and 
local governments desperately sought ways to curb this expand- 
ing system that, by the mid-1990s consumed nearly one out of 
seven dollars spent in the US. 



Managed Care Emerges 

What could be done? One proposed solution was government 
regulation, but that approach has not been effective. For ex- 
ample, the governmental step of ratcheting down fees has had 
limited benefit since total cost is influenced more by the number 
of service units consumed than by the cost per unit of service. 
Except in the case of Medicare's Diagnostic -Related Group 
reimbursement forinpatients, governmental systems have been 
inept at curbing excessive utilization. 

Managed care emerged from the crucible of the private 
sector where innovations can be more readily devised and 
contracts more effectively negotiated. Some insiu^ance compa- 
nies changed their approach. The use of the credit card was 
monitored. The department store began to look at whether its 
products were effective, rather than just tabulating a list of sales. 
New questions were asked: Are the products sold to the con- 
sumer \iu\y needed and effective? Would other products give as 
good an outcome at less cost? Is there duplication of products 
to serve a given need? Do some products actually harm or cause 
increased risk for the consumer? 

Practicing physicians may be frustrated by the questions 
raised. We physicians know there has been much waste of 
resources, but we often feel irritated by the steps taken to 
diminish the excesses. Under managed care, patients typically 
endure a learning curve that is sometimes aggravating, but the 
yearly increase in premiums for health insurance has decreased 
from greater than 25 % five years ago to zero (or less) now. Both 



78 



NCMJ March/April 1996. Volume 57 Number 2 



physicians and patients tend to forget the reasons for the 
changes and overlook the gains that have occurred. 

The managed care industry has effectively responded to 
societal demands to control the rapid inflation of health care 
costs. Practicing physicians have been challenged to pay more 
attention to preventive care and early detection. Furthermore, a 
number of studies show no compromise in patient outcomes. 
Quality of care has improved. Outcome measures — the rates of 
premature delivery, childhood immunization, and mammogra- 
phy for women older than 50 — are better for HMO-covered 
patients than those with indemnity insurance.''^ 



Physicians' Role 

Without doubt, managed care is upon us. It fills a societal need, 
and enrollment is growing rapidly. Private industry has experi- 
enced the value of the system, and Medicare and Medicaid will 
be expanding use of managed care methods. Of course, there is 
a spectrum of managed care systems. Some are more clinically 
sound and less physician-aggravating than others. It is simplis- 
tic to think of managed care as a monolithic entity. Typically, 
the better plans have strategic input from and direction by 
physicians. As with any innovation, adjustments and fine 
tuning are needed to optimize the systems. 

I would emphasize that it is critically important for physi- 
cians to play major roles in directing and shaping the managed 
care system. It is useless to try to block its progress. We must use 
our input to guide the evolution of the system so it effectively 
serves our patients. Businesses and investors have become ac- 
tively involved as huge amounts of capital are necessary to fund 
this new industry. Still, the physician remains indispensable. 

The transition phase, in which we now live and work, will 
be the most difficult time for physicians. In a few years a new 
era will have emerged. Those paying for the credit card will 
have their panic relieved. Patients will, out of necessity, adapt 
to the new system. Innovations in financing will shift incentives 



for the providers. Better tools for measuring outcomes will be 
developed. A body of research data will guide the delivery of 
good, cost-effective care. Quality assurance will become com- 
monplace. 

Already, it is apparent that the new system will shift the 
distribution of doctors toward more primary care physicians 
and fewer proceduralists. The transition will be disruptive, but 
the job market will eventually bring a balance to the supply and 
demand of professionals. Our training programs will have to 
adjust to these changing needs. 

While the infrastructure and financing mechanisms are 
changing, it is reassuring that in the op)erating room, the 
examining room, the emergency department, or the laboratory, 
patients still must be cared for by competent clinicians. There 
is no prospect that governmental fiat or business decisions will 
change that The design of health care delivery must be clini- 
cally sound with decisions made in the best interests of patient 
care. Only effective physician participation can achieve these 
goals. In an environment of market competition, and judged by 
the barometer of enlightened public opinion, the system that 
provides high quality, cost-effective care and patient satisfac- 
tion will ultimately prevail. As these new systems undergo 
evolution and continuous improvement, physicians need to 
consider not only individual patients, but also the public health 
and the greater good. 

If we maintain our focus on patient care rather than profit 
and loss, our collective voice will be heard. No matter the eco- 
nomic system or its incentives, physicians must sustain their 
professionalism and remain advocates for good patient care. 
The potential for conflict of economic interests exists in a fee- 
for-service system just as it does under capitated contracts. In 
both cases, the protection of the patient's interests rests on the 
integrity and ethics of the physician. Physicians need to be stra- 
tegic players, striving for a health care system that uses finite 
resources to serve all our citizens. Managed care is an effort to 
accomplish those goals. Rather than resisting it, our profession 
needs to guide managed care to better serve our patients. □ 



References 

1 Healthsource, NC Patient Survey. Raleigh, NC, 1994. 



2 Healthy People 2000, Public Health Service ( 1 990), National Health 
Promotion and Disease Prevention Objectives. Washington, DC. 



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NCM J March/April 1996, Volume 57 Number 2 



79 



THE ANATOMY OF MANAGED CARE 

Can We Serve Two Masters? 

The Ethics of Managed Care Practice 

Anonymous 



As managed care organizations (MCOs) move into North 
Carolina, physicians find themselves saddled with rules, re- 
quirements, and styles of practice to which they are not accus- 
tomed. Cost containment is the watchword of MCOs and they 
are fundamentally transforming the way North Carolina doc- 
tors practice medicine. 

MCOs are the agents through which more and more pa- 
tients are paying for medical care today. It is important to 
recognize an important social function of these organizations — 
to hold down the rising expense of medical care through 
rationing. Rationing of medical resources can be accomplished 
by one of two mechanisms: cost, or the scarcity of resources. 
Because of the widely held belief that everyone is entitled to 
medical care, rationing by cost 



other relationships in our lives. Entrusting our lives, our most 
personal thoughts and feelings to a physician cannot be done 
without the protection of our public affirmation of trustworthi- 
ness. The Hippocratic Oath, symbolic of this ideal, is our 
traditional declaration that we value the public trust and will act 
in the best interests of our patients. 

The one tenet of medical ethics that has governed the 
behavior of physicians is an uncompromising advocacy of the 
individual patient This rule has crystallized over the centuries 
because of an implicit social covenant: "If we can trust you to 
do the best for patients and take care of them, we will leave you 
alone to do your work as a professional, as a physician." This 
compact has given physicians a special place in society, a 
position assured by the 



has not been acceptable in our 
society. For this reason MCOs 
accomplish rationing by mak- 
ing services unavailable under 
the guise of "cost contain- 
ment." 

Managed care organiza- 
tions are much more than the 

"insurance companies" physi- 
cians have previously dealt with. When physicians sign man- 
aged care contracts they sign onto a whole new style of medical 
practice, a new way of dealing with patients, a new and altered 
profession. Physicians must understand that they will be used 
by the MCOs as instruments of rationing. The primacy of the 
doctor-patient relationship is fundamental to the practice of 
medicine as embodied in the "Hippocratic tradition." This time- 
honored tradition is currently under siege by managed care 
companies who attempt to mold physician behavior to a cost- 
centered rather than a patient-centered ethic. 

The work of physicians in and for society is unique. Our 
relationship with patients is sacred, deeper and beyond most 

Editor's note: The author of this article wishes to remain anony- 
mous. See sidebar, next page. 



The (Hippocratic) tradition is under 
siege by managed care companies 

who attempt to mold physician 

behavior to a cost-centered rather 

than a patient-centered ethic. 



public's trust in our work. But 
trust is fragile, and physicians 
risk losing it if they accept the 
new ethic the MCOs are hand- 
ing them: the negative role of 
"gatekeeper." 

The negative gatekeeper, 
a creation of MCOs, repre- 
sents a new challenge and pit- 
fall for American medicine. As negative gatekeepers, physi- 
cians must restrict, under constraints of self-interest, the avail- 
ability of medical services to patients. The withholding of 
payments, the award of bonuses, the payment by capitation, and 
the "economic credentialing" are a few of the methods by which 
MCOs control physician behavior and achieve cost control and 
rationing. 

I do not mean to say that withholding treatment is always 
bad, nor is trying to contain costs in medical care. Physicians 
have always aimed to use only treatments that are both effective 
and beneficial. MCOs, however, use financial incentives to 
coerce physicians into becoming the instruments of rationing. 
Their inducements produce physician behavior that conserves 
dollars for the doctor and the MCO, but inevitably conflicts 
with the doctor's role as patient advocate. 



80 



NCMJ March/April 1996. Volume 57 Number 2 



Today, physicians are being "retrained" for a new and 
different function: containing costs. This retraining is occurring 
at all levels: medical school, residency, and on into practice. 
Many of us, particularly those just starting a career, are not 
aware of this new function. It just seems like the "way things 
are." Some of us have actually found a new sense of purpose in 
the mission of cost containment, a sense of being part of a larger 
social movement. But struggling to adopt a tempting new social 
role as cost container is not the laudable objective of doctoring. 
That lies in finding the precise posture in this movement that 
will preserve medicine's traditional values. 

The negative gatekeeper is the embodiment of the new 
ideal of cost containment. This ideal influences the behavior not 
only of primary care doctors but of specialists as well. The 
immediate result will be the public's loss of trust in physicians' 
motivation. "Is he worried about my well being, or his with- 
hold?" "Is she worried about the resources of the plan or my 
medical care access?" How many newspaper articles have 
discussed gatekeepers who refused care because of cost to the 
physician or the plan. It won't take many such reports to erode 
public trust. And once that is gone, physicians will be seen as 
obstacles to rather than the providers of care. In our "new" role 
as cost containers, we obstacles will be mere technicians, 
puppets of the MCOs. Our professionalism, our autonomy, will 
have vanished. 

This present moment must not be viewed by physicians as 
the "forever" of our great profession. Two thousand years of 
loyalty to our patients is too much to relinquish because of a 
market system that gave birth to managed care. Nothing can or 
should replace the individual doctor-patient relationship. Our 
intimate interactions with patients should be efficient, but must 
also nurture and protect the tacit social bargain of trust. In 
dealing with patients, doctors must not act as representatives of 
managed care "decision by committee," especially committees 
so keenly interested in the bottom line. One-on-one for our 
patients is our only responsible choice. 

Physicians should not be the instruments through which 
MCO policies are implemented. It is not the CEO of "WeCare 
HMO" who tells the patient he must go home in pain, with 
sutures, constipated, fearful; it is the doctor who must. The 
medical director of WeCare HMO does not tell the mother of 
four she must go home six hours after delivering her fifth child; 
the doctor does. No chairman of the board of WeCare HMO 
tells the double hernia patient, dutifully doped with local 
anesthetic, to go home uncertain and afraid of what will happen 
when the pain settles in; the doctor does. Assembly line medi- 
cine is not conducted by the executives of the MCOs, but by 
doctors who have allowed themselves to become their ambas- 
sadors. 

What should physicians do in this new practice environ- 
ment? First, we should reaffirm our advocacy of the individual 
patient. We are not the rationers of public resources; society 
must take that role. We will stand with and at the side of our 
patients. In addition, we will practice cost-effective, compas- 
sionate medicine, avoiding unnecessary care and over-treat- 



ment of the terminally ill. We should support ideas and legisla- 
tion that strengthen and enhance the doctor-patient relationship 
(for example, high deductible insurance policies with medical 
savings accounts, and Senator John Kyi's bill to legalize private 
contracting between physicians and Medicare enroUees). We 
must educate the public about our position in the struggle to 
control costs, and help to expose the untenable position of the 
managed care lackeys. Doctors cannot be both the patient's 
advocate and a cost container for an MCO. Even after all these 
years, the message is still the same: "We cannot serve two 
masters." 

Why the Journal is 
Publishing an 
Anonyntous Article 

The accompanying article was submitted by a North 
Carolina physician, known to your editors, with the re- 
quest that the article be published anonymously. As a 
general rule the Journal does not publish unsigned ar- 
ticles or letters. We have always felt that the essence of 
scholarly communication within a learned profession in- 
volves the willingness of an individual to accept and 
acknowledge the consequences of his/her words by sign- 
ing an article. As a general dictum of medical journal 
publishing, if you don't have the courage to sign your 
name, then the article doesn't get published. 

Why did we make an exception this time? First, the 
author made a cogent case as to why he/she needed to 
remain anonymous. It is increasingly difficult, the author 
asserted, to voice any criticism of managed care organi- 
zations without a threat of reprisal — of being shut out of 
managed care patient referral networks, being "black- 
balled''from contract negotiations, or being denied access 
to patient referrals. Second, in spite of vigorous denials 
from managed care organizations, we frequently hear of 
"gag clauses" in physician contracts designed to prevent 
physicians from criticizing the managed care organiza- 
tions they work for or with. Third, recent issues of L/SA/ews 
and World Report and Time have devoted significant 
space to stories of physicians allegedly fired from man- 
aged care organizations or shut out of patient care net- 
works because they spoke their mind or published articles 
critical of managed care entities. 

Your editors, therefore, agree that the author's re- 
quest for anonymity is based on a valid concern. The 
accompanying article represents only the author's views 
and not those of the editors. It should not be construed as 
representing the editorial opinion of the North Carolina 
Medical Journal r\o( as policy of the North Carolina Medi- 
cal Society. The editors do feel, however, that real dia- 
logue about managed care is in the public interest. The 
need to provide a forum for all views persuades us to 
override our general rule against unsigned articles. 

— Edward C. Halperin, MD, Deputy Editor 



NCMJ March/ April 1996, Volume 57 Number 2 



81 



The road ahead will not be easy. In the current environ- 
ment, keeping the covenant with our patients may be all but 
imfTOSsible. Perhaps it can only be maintained by turning to 
patients for direct reimbursement. If they are poor, we will give 
them charity; if they have means, we will be paid. By so doing, 
physicians can break the yoke of managed care contracts that 
undermine the public's trust in us. "Impractical!" "Impos- 
sible!" I have heard those retorts, even from our medical 
leaders. But if physicians want to maintain a semblance of 
professional autonomy, there is no other road. 

I have sometimes wondered whether physicians today 
actually believe in themselves and the skills they might "offer" 
in the open market. Doctors will gripe about having to write to 
a third party for three months to collect $25. Would it not be 
simpler to just ask the patient for it? Or is immediate, "face to 
face" more difficult than dealing with impersonal electronic 
claims? Will we really end up better off financially and profes- 
sionally by selling our souls to the third parties for their rapidly 



approaching "Medicaidesque" reimbursement? 

By turning directly to patients for payment we will be 
dealing in a new environment of freedom. Physicians will find 
that they are dealing with reborn patients. On a new stage, 
physicians and patients could meet as individuals in a real 
market system — isn't that what we say we want anyway? — 
with our own agendas, not as pawns of MCOs, playing our parts 
in a setting of uncertainty and lurking distrust 

As the debate continues, physicians must resolutely main- 
tain the courage to promote these fundamental ideas. Accusa- 
tions of being "behind the times" or "resistant to change" should 
not deter us although the cries will be plentiful and loud. Our 
vision of ourselves as physicians must see beyond the 50-year 
history of third-party reimbursement, back 2,500 years to the 
Father of Medicine. We must embrace the historic tradition of 
advocacy for the individual patient In the end, this addition will 
win. It is for the good of society, the profession, and our 
patients. □ 



Reach the NC Medical Journal Via E-Mail 

Readers can now reach the Journal via electronic mail. Please direct letters to the editor, general 
correspondence, and reprint requests to: yohn0001@mc.duke.edu 

A Journal home page on the World Wide Web is in the works. Look for updates in future issues. 




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NCMJ March/April 1996. Volume 57 Number 2 



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THE ANATOMY OF MANAGED CARE 

The Future of Oncology 
Under Managed Care 



Jeffrey C. Acker, MD 



The escalating costs of health care have moderated in recent 
years, but expenditures still outpace inflation. The United 
States allots a far higher percentage of its gross national product 
to health care (14%) than do its main business competitors in 
Western Europe and Japan, putting the US at an economic 
disadvantage. In an attempt to contain those costs, an increasing 
number of patients are being offered managed care rather than 
traditional fec-for-scrvice medicine. An estimated 65 million 
lives will be covered by some type of managed care by the end 
of this year, a circumstance which, over time, will likely bring 
many changes in how we oncologists care for our patients. 



The Economics of Oncology 
and Managed Care 

Costs allocated to cancer care — prevention, diagnosis, and 
treatment of mahgnant diseases — account for approximately 
5% of US direct health expenditures. Direct costs amount to 
29% and indirect expenses (opportunity losses to patients and 
their caretakers due to morbidity and mortality of disease), to 
7 1 % of the total annual cost of cancer — an estimated $96 billion 
in 1990.' In 1995 citizens older than 65 accounted for just over 
12% of the US population, or about 30 million people. We can 
predict that this number will increase to more than 50 million 
(21% of the population) by 2020. Since malignancies are 
generally adisease of the elderly, the "aging of America" means 
that cancer care will constitute an increasing proportion of 
health care expenditures. We will need to evaluate the eco- 
nomic utility of cancer care in terms of patient outcomes. While 
such an evaluation is in its infancy, we can examine the 
processes involved and speculate as to how clinical practice 
will change. 



Dr. Acker is a Radiation Oncologisf at Regional Radiation 
Oncology, 445 Biltmore Ave., SuiteG-1 09, Asheville 28801 , and 
an Assistant Consulting Professor, Department of Radiation 
Oncology, Duke University Medical Center, Durham. 



Most managed care systems use some form of "gatekeeper," 
a practice structure which requires that referrals to specialists be 
made by a designated primary care physician (who has incen- 
tives to limit specialist use). In the short term, this arrangement 
may reduce the need for the services of oncology specialists 
because managed care organizations will require primary care 
physicians to play a greater role in cancer patient management. 
Primary care physicians may become the chief caregivers 
following cancer diagnosis and oncologists may be relegated to 
the role of consultants. This is quite different from the current 
situation in which oncologists deliver much of the cancer 
patient's "primary care" in addition to cancer therapy. Managed 
health care plans often limit the number of visits to a specialist 
to three or fewer after completion of therapy, making the 
primary care physician responsible for long-term care. Since 
primary care physicians receive little formal instruction in the 
management of the wide variety of cancers seen by oncologists, 
and since medical knowledge grows continually, primary care 
practitioners face a formidable challenge in staying current in 
this one specialty, let alone the multitude of other areas with 
which they must be familiar. 

For these reasons most primary care gatekeepers will find 
it difficult to manage well the long-term care of cancer patients, 
a role for which medical and radiation oncologists are specifi- 
cally trained. As the system evolves, the primary decisions 
about curative and palliative treatment of cancer will likely be 
made by those sijecifically trained in oncology. Given a diag- 
nosis or suspicion of cancer, most patients will automatically be 
referred to an oncologist or "oncology board" for advice about 
evaluation and management, especially in capitated systems 
where there is incentive to use the most cost-effective work-up 
and efficacious treatment. It costs less to aggressively and 
successfully treat a malignancy at the outset rather than to 
finance the ongoing management of persistent or recurrent 
disease. 

As the managed care market evolves within a geographic 
area, oncology will likely undergo payment and care distribu- 
tion transitions to some form of capitated arrangement; physi- 



84 



NCMJ March/April 1996, Volume 57 Number 2 



cian groups, multispecialty groups, or hospital-based practices 
will assume risk for the covered lives. Most care in North 
Carolina presently operates under some variation of fee-for- 
service reimbursement, but from the history of more mature 
managed care markets on the West Coast, in the Northeast, and 
in Minnesota, we can predict a transition from discounted fee- 
for-service practice to a substantially capitated system in North 
Carolina (see related article, page XX). Cost containment will 
be difficult to achieve unless specialist care is capitated, either 
individually or as part of larger multispecialty organizations. 
Some institutions are currently submitting proposals for global 
pricing or episode-based reimbursement for common cancers 
such as early stage breast cancer.^ This capitated pricing method 
defines the services used to evaluate and treat patients with a 
particular diagnosis, from discovery through long-term follow- 
up, and uses each service's current cost and historical rate of use 
per patient to arrive at an average cost. Because of the current 
lack of solid information about cost and outcomes, it is difficult 
to determine accurate capitation rates for many aspects of 
cancer care. 

By definition, capitation will limit resource utilization. In 
a capitated system the use of limited funds must be prioritized 
so that more resources are spent on those who have the most to 
gain from treatment Expensive, marginally beneficial treat- 
ments may become unavailable, until studies demonstrate their 
efficacy and benefit in terms of economics or quality of life. For 
example, in radiation oncology, the use of costly techniques 
like conformal radiotherapy, stereotactic radiosurgery, or high- 
dose-rate brachytherapy will likely be tightly regulated. In 
medical oncology, strict usecriteria will be applied to high-dose 
chemotherapy using bone marrow or peripheral stem cell 
support, or growth factors like granulocyte colony stimulating 
factor (G-CSF), granulocyte-monocyte colony stimulating fac- 
tor (GM-CSF) or erythropoietin. Prescribers of these therapies 
will need to justify their cost-effectiveness and utility. In the 
short term, we will have only minimal information on which to 
base such decisions, but managed care is an excellent system in 
which to collect the necessary data. We will see a proliferation 
of population-based outcome, cost-effectiveness, quality-of- 
life, and patient-preference information that will permit better 
decisions to be made. 

Equally effective treatments will be differentiated by cost 
and patient preference. For example, radical prostatectomy and 
radiotherapy are essentially equivalent treatments for uncom- 
plicated, clinically localized prostate cancer. Recently, the 
overall cost of surgery was considerably higher than that of 
radiotherapy, due primarily to lengthy post-operative hospital- 
ization. Under pressure to decrease the length of hospital stay, 
the cost of these competing therapies has converged. In the 
treatment of early-stage breast cancer, segmental resection and 
post-operative radiotherapy costs more than modified radical 
mastectomy but less than mastectomy and reconstruction. Eco- 
nomic pressiu"es will make equivalent treatments more compa- 
rable in cost, leaving patient choice as the primary determinant 
in selecting similarly priced therapies. 



Choice of palliative care will be directed by cost and 
potential clinical benefit. Less-expensive therapies will be used 
first and accepted, yet more expensive, treatments held in 
reserve. Radiotherapy for painful bone metastases will be 
discouraged in favor of cheaper pain medication. Managed care 
organizations will set specific guidelines and indications for use 
of palliative radiotherapy and chemotherapy. It is likely that 
aggressive end-of-life care will become less common. 

Clinical practice guidelines are being prepared by the 
National Comprehensive Cancer Network (NCCN), a nation- 
wide group of 1 3 prominent cancer centers. The NCCN is using 
multidisciplinary panels to determine the ranges of acceptable 
therapies and to outline acceptable treatment options for a 
variety of clinical situations. These guidelines are designed to 
assist clinicians in making therapeutic decisions, but they also 
coincide with the goals of managed care, promoting practice 
conformity and cost reduction.' For the near term, the guide- 
lines will be based on currently accepted practice and treatment 
methods; as more economic and quality-of-life data become 
available, they will be refined and tightened. Treatment that 
falls outside specified guidelines will not be reimbursed under 
what remains of fee-for-service medicine (except in special 
circumstances). In a capitated system there will be no incentive 
to "try this to see if it helps" since this practice increases costs 
but rarely benefits patients. 



Creating a Data-Driven System 

How will cost effectiveness, quality of life, and patient prefer- 
ence information be obtained and evaluated? The patient popu- 
lations of managed care organizations will be sufficiendy large 
to address these issues. In the near future, it's likely that all 
Phase III clinical trials will assess these items. In addition to 
their ability to improve survival or to result in therapy-related 
morbidity, new treatments will be judged on cost and patient- 
rated quality of life ("Were the side effects and time lost in 
therapy worth the extra two months of life?"). Managed care 
companies are unlikely to reimburse patients for care in clinical 
trials now in place, but that may change once studies begin to 
gather data on cost effectiveness and overall patientexperience. 
Society must decide what it is willing to 'pay' to extend 
life. In terms of cost per year of life saved, treatment of cancer 
is relatively economical compared with other common dis- 
eases. Adjuvant chemotherapy for stage C colon cancer costs 
about S2,(XX) per life year gained; standard adjuvant chemo- 
therapy for stage II breast cancer in a premenopausal woman 
costs about S5,(X)0 per life year gained; standard treatment of a 
non-small cell lung cancer costs approximately S lO.CXK) per hfe 
year gained." Compare these figures with the S46,(XX) per life 
year gained by renal dialysis or the $17,4(X)-$133,(X)0 per Ufe 
year of life gained by coronary artery bypass graft' The quality 
of these 'life years gained' will be studied closely and the results 
integrated into society's decisions about the cost utility of 
specific therapies. 



NCM J March/ April 1 996, Volume 57 Number 2 85 



Most of the savings in long-term cancer care will come 
from disease prevention, and from early disease detection. At 
present, a proportion of cancer care (20%-30% by some esti- 
mates) is considered unnecessary. Managed care will remove 
the incentives for offering marginally beneficial care, resulting 
in cost savings, but these savings pale in comparison with what 
can be saved by screening for early cancer detection and, more 
importantly, prevention. Now there are few incentives to pro- 
mote early detection and prevention, but under managed care 
modification of patients' risk factors, resulting in decreased 
incidence of malignancy, will benefit the entire system. For 
example, strategies promoting smoking cessation are very cost- 
effective, reportedly costing $1,300 per year of life saved. 
Screening programs like mammography and the prostate-spe- 
cific antigen blood test are less clearly cost saving, but are 
relatively cost effective.' Given their benefit to patients, these 
programs will likely remain a priority. 



and very few providers practice only this aspect of surgery. 
According to the NC Health Planning Commission, oncology 
overall is underserved in the state. 

Another important difference between oncology and other 
specialties involves location of treatment Managed care plans 
send patients needing tertiary care services (such as cardiac 
surgery, neurosurgery, and oncology) to a few "centers of 
excellence." This may be acceptable for surgical care, but 
oncologic therapy often requires many cycles of chemotherapy 
or a series of radiation treatments that require patients to spend 
much time away from home, away from their physical and 
emotional support systems. Cancer therapy patients indicate 
that staying close to home is a priority, meaning that the 
delivery of care will continue to be community-based. 



Conclusion 



How Many Oncologists 
Will We Need? 

Capitation decreases physician utilization rates by 1 5%-50% in 
a variety of clinical situations. Figures from HMO staffing 
patterns indicate a physician glut in many specialty areas.'* As 
a result, we will need to redistribute physicians to different 
fields of medicine, creating an overall gain in primary care and 
a loss in many specialties. Interestingly, this is does not pertain 
to hematology/oncology where managed care staffing parallels 
the current supply . It does not appear that medical oncology will 
be overstaffed, considering the aging US population with its 
increase in cancer cases. The same cannot be said for radiation 
oncologists however. Too many are being trained even for 
current utilization rates, and this will be exacerbated by poten- 
tial decreased utilization under managed care.' The federal 
government's failed attempt at health care reform had recom- 
mended a 41% reduction in radiation oncology residency 
positions over the next five years. It is difficult to know how we 
stand with respect to surgical oncology because that field 
involves a number of different specialties and subspecialties. 



Managed care will change the way cancer patients are treated in 
the future. Despite the fear that primary care physicians will be 
expected to manage the cancer patient, it is likely that oncologists, 
in close consultation with primary care doctors, will still fulfill 
that role. Most medical care will be capitated, removing the 
incentives present in fee-for-service medicine that promote 
marginally beneficial treatment. More effort will be focused on 
preventing malignancies. Cost-effectiveness and quality-of- 
life data will become as important as efficacy in determining 
therapy. Managed care entities will provide outcomes data that 
will allow better insight into the global effects of treatments and 
better choice of therapy. The historical patient-doctor relation- 
ship will change, but physician and patient will still choose the 
most beneficial management strategy, as long as their choice 
falls within the scope of clinical practice guidelines. Changes 
will occur in oncology staffing numbers and locales, but not as 
much as in many other specialties because there will be an 
increasing demand for oncology care. □ 



Acknowledgment: The author thanks Lynda M. Acker, PhD, 
for her many helpful suggestions and ideas. 



References 

1 Schuette HL, Tucker TC, Brown ML, Potosky AL, Samuel T. The 
cost of cancer care in the United States: implications for action. 
Oncology (Supp)1995;9:19-22. 

2 Wodinsky HB, Stein MV, Friedman NS. Global pricing for cancer 
care: one hospital's preliminary report. J Oncology Management 
1994; March/April: 18-22. 

3 Winn RJ. The role of oncology clinical practice guidelines in the 
managed care era. Oncology (Supp) 1995;9:177-84. 

4 Evans WK, Will BP, Berthelot JM, Wolfson MC. The cost of 
managing lung cancer in Canada. Oncology (Supp) 1995;9: 147-54. 

5 Smith TJ, Hillner BE. Decision analysis: a practical example. 
Oncology (Supp) 1995;9:37-45. 



6 Thompson IM, OptenbergSA. An overview cost-utility analysis of 
prostate cancer screening. Oncology (Supp) 1995;9:141-5. 

7 Weiner JP. Forecasting the effects of health reform on US physician 
workforce requirement: evidence from HMO staffing patterns. 
JAMA 1994;272:222-30. 

8 Coojjer RA. Perspectives on the physician workforce to the year 
2020. JAMA 1995;274:1534-43. 

9 Flynn DE, Hussey DH. Review of the manpower issue in radiation 
oncology. Int J Radial Oncol Biol Phys 1992;24:909-12. 



86 



NCMJ March! April 1996, Volume 57 Number 2 



^^-^^ 



fO^ 



V^ NORTH CAROLINA MEDICAL SOCIETY 

Health Watch 



VOL 57 - NO. 2- MARCH/APRIL 1996 



Child safety and accident prevention 



AGE-APPROPRIATE INTERVENTIONS 

by C. Tate Holbrook, III, MD, FAAP 



Did you know that each year in the United States more 
than 16 million children are seen in doctors' offices and 
emergency rooms because of an injury or accident? Over 
600,000 children are hospitalized and greater than 20,000 
will die from an accidental cause. Deaths from injury account 
for more loss of life and disability than all other disease 
causes combined. Most injuries are no accident! More than 
90% of injuries are both predictable and preventable. Injuries 
account for greater than $10 billion in direct health care and 
compensation costs, not to mention the enormous indirect 
costs of loss of future productivity for the child injured during 
his or her youth and the enduring pain and suffering of the 
families of children lost through accidental death. 

Almost half of injury deaths are related to motor vehicle 
accidents — including automobile occupant, bicycle, and pe- 
destrian injuries. Most of these are related to human error — 
traveling at high speed, under the influence of drugs or 



C. Tate Holbrook, III, MD, FAAP, is a pediatrician with 
Greenville Pediatrics Services, Inc. 



alcohol, or disobeying simple safety precautions, and are thus 
predictable and preventable. Other leading causes of child- 
hood mortality and morbidity due to unintentional injury or 
accident include drowning, bums, choking, falls, poisoning, 
sports activity, and firearms. Most of these injuries are also 
preventable. 

All children and adolescents are at risk, and certain 
children may be at greater risks: boys (especially those with 
Attention Deficit Hyperactivity Disorder [ADHD]), children 
with previous accident records, children in low income 
families, children of young mothers, and children suffering 
from emotional stress. All children deserve to live in a safe 
environment, free of risk of injury. This is the primary job of 
parenthood. Our environment can be made safer through 
anticipatory guidance programs, aimed at age-specific safety 
counseling. 

Routine well-child care must include time to discuss 
safety issues for infants, children, and adolescents. This 
counseling must be directed at the primary care giver as both 
the most visible role model for a child's behavior (action and 



NCMJ March/April J 996, Volume 57, Number 2 



87 



thought) and as the person(s) most likely to have control over 
a child's environment. Safety counseling should be more 
directed to the child as he or she becomes older and certainly 
by the time they reach adolescent age. Adolescents eventu- 
ally become responsible for their own behavior and misbe- 
havior. Recommendations made by the American Academy 
of Pediatrics (AAP), the American Academy of Family 
Physicians, the Canadian Task Force on Periodic Health 
Examination, and the US Preventive Services Task Force all 
include age-specific safety counseling provided during rou- 
tine well-child visits. To assist pediatricians in providing 
child safety counseling, the AAP developed The Injury 
Prevention Program (TIPP). TIPP offers a safety counseling 
schedule, age-appropriate safety surveys for parents, and 
age-specific safety handout materials for families. All or 
some of these materials may be used by physicians providing 
anticipatory guidance or counseling. 

Office-based counseling for injury protection should 
address these age-specific guidelines: 



Infants and Pre-Schoolers 

Traffic safety 

Child safety restraints (car seats) should be used, starting with 
the ride home from the hospital. These seats should only be 
used in the back seat and face the rear window until the child 
weighs 18 to 20 pounds. Safety seats should be used until 
children weigh 40 pounds. Seat belts should be worn by all 
passengers. This is a legal requirement in all 50 states. 

Burn prevention 

Hot water heaters should have temperatures set between 
120°F and 130°F to prevent scalds. Smoke and carbon 
monoxide detectors should be installed and maintained in all 
homes. Electrical outlets should be covered with plastic 
guards and caution taken with boiling water, irons, hair 
curlers, and space heaters. Children should not be allowed 
to play around stoves or grills. And certainly water-resistant 
or water-proof sunscreen with a sun protection factor (SPF) 
of at least 15 should be used in warm summer weather. 

Fail prevention 

Parents should place safety gates (preferably not the accor- 
dion type) across stairways (top and bottom) and install 
window guards on all upper floor windows. Use of infant 
walkers is discouraged. 

Ctiolcing/suffocation prevention 

Small objects that might cause suffocation (such as plastic 
bags) and choking (such as toy parts, coins, hard candy, and 
peanuts) must be kept out of reach of small children. 



Drowning prevention 

Children may drown in very small amounts of water such as 
found in bathtubs, toilets, wading pools, and buckets. Back- 
yard swimming pools, spas, or wading pools should be 
surrounded by fencing. Children under five should not swim 
without supervision, despite "knowing how to swim." 

Poison prevention 

Medicines and household products (cleaners, furniture pol- 
ish, chemicals, etc.) must be kept out of sight and reach of 
curious children. Child safety latches should be used to keep 
children out of potentially dangerous drawers and cabinets. 
The local poison control center telephone number should be 
posted near the kitchen phone and syrup of ipecac available 
to induce vomiting in the event of a poison ingestion. 

Watct) for wandering 

Common sense should tell us to always respect the exploring 
and inquisitive nature of toddlers and young children. These 
are the children who suffocate in old freezers or trunks, who 
wander into the neighbors' yard and fall into an open swim- 
ming pool, or who are struck in the head by a rock thrown 
from a lawn mower or lose a limb from an accident suffered 
involving a riding mower. 

Plan for emergencies 

Parents can lessen their child's risk of severe consequence 
from injury by being trained in infant and child cardiopulmo- 
nary resuscitation (CPR) and by knowing how to call for help 
(911) in an emergency situation. 



School-Age Children 
Traffic safety 

All occupants in a motor vehicle should continue to wear 
seatbelts. Children should ride in the back seat if possible, 
and those children weighing less than 70 pounds (32kg) 
should sit in a properly secured booster seat. If a shoulder 
strap (belt) crosses the child's face or neck where buckled, it 
should not be worn, but instead tucked behind the child's 
shoulders. No one should ride in the bed of a pickup truck and 
all-terrain vehicles should only be used by licensed individu- 
als or those over 16 years old. Parents should review safe 
pedestrian habits (stop, look, and listen) with their children. 
Helmets should be worn at all times while bicycling or 
skating. The use of protective equipment (pads and gloves) 
will also reduce skating injiuies. 

Water safety 

Children over five years of age should be taught how to swim. 
Public leam-to-swim programs are available in most towns. 
Young children should never be allowed to swim alone and 



88 



NCMJ March/April 1996, Volume 57, Number 2 



should only swim in designated safe areas. They should be 
taught about the hazards of neck injury from diving into 
shallow water and the importance of wearing a life preserver 
while boating. As with all-terrain land vehicles, only chil- 
dren over 16 years old should operate motorboats and espe- 
cially jet skis. Only by the example of parents and others will 
our children learn to respect water safety. 

Sports safety 

The importance of wearing proper protective equipment and 
being in physical condition cannot be overemphasized. Sports 
injuries occur less in prepubescent children. This age there- 
fore, becomes a good time to start children in organized sport 
activities. 

Firearm safety 

Because of the inherent risks to children of in-home firearms, 
especially handguns, parents are encouraged to keep hand- 
guns out of the home. If guns are kept in the home, they 
should be kept unloaded and the ammunition stored in a 
separate place. 



Adolescents 

Traffic safety 

Only licensed drivers should be allowed to drive. Seatbelts 
use should be encouraged and the role of alcohol on traffic 
safety discussed. Adolescents should be advised to avoid 
alcohol and other drugs especially when driving. They 
should avoid riding with someone who has been drinking. 
Helmets for motorcycle, bicycle, and skating protection must 
become a priority. 

Water sports safety 

Parents should also discuss the efforts of alcohol on one's 
participation in water and snow-related activities (boating, 
skiing, snowmobiling, etc.) The use of proper equipment and 
safety measures must be taught and encouraged. Over 
600,000 injuries occur each year in the five million partici- 
pants in high school sports in the US. Appropriate condition- 
ing and equipment use will prevent many of these injuries. 

Firearm safety 

In-home firearms pose a predictable danger during adoles- 
cence due to the increased risk of impulsive behavior prompt- 
ing the unplanned use by teenagers resulting in homicides, 
suicides, and accidental injury. Firearms should be kept 
unloaded and locked up and the ammunition stored in a 
separate, locked place. 



Safe sex 

While abstinence is the best approach we can teach our youth, 
they don't always listen. We should take every opportunity 
that presents itself to discuss abstinence or safe sex and the 
prevention of unwanted pregnancy and venereal disease. 



So What Can Parents Do? 

Talk to your children! Begin teaching safety rules at a 
young age and always practice what you preach. All children 
are adventurous, especially our preschool kids. These young 
explorers often have no fear, while our teenagers often 
assume an accident could never happen to them. Injuries 
remain the leading cause of death and disability for our youth. 
We, as parents, can make a difference. Appropriate counsel- 
ing can alert our children to risky behaviors and unsafe 
environments. But, unless we face the fact that accidents are 
preventable and the responsibility of changing whatever our 
children think and do about safety, we're doomed to fail. 
Remember, the number one killer of children and adolescents 
cannot be cured, but it can be prevented. Safety is no 
accident. 



Parent Resources 

injury prevention materials 

The Injury Prevention Program (TIPP) 
and Make Every Ride a Safe Ride 
American Academy of Pediatrics 
PO Box 927 

Elk Grove Village, IL 60009-0927 
Phone (800) 433-9016 



National Safe Kids Campaign 

(injury prevention magazines, brochures, 

videos, posters) 

1 1 1 Micnigan Ave., NE 

Washington, DC 20010 

Phone (202) 939-4993 

Child Safety: How to Keep Your 

Home Safe for Your Baby 

American Academy of Family Physicians 

8880 Ward Parkway 

Kansas City, MO 641 14-2797 

Phone (800) 944-0000 



NCMJ March! April 1996, Volume 57, Number 2 



89 



U.S. Consumer Products Safety Commission 
(pamphlets on accident prevention from 
household toys, household products and other items) 
Publication Requests, 
Washington, DC 20207 
Phone (800) 638-2772 

US Department of Transportation 

National Highway Traffic Safety Administration 

(brochures on motor vehicle injury and 

alcohol-related traffic injuries) 

Phone (202) 366-2105 



References 

us Public Health Service, Safety Counseling in Children and 
Adolescents, American Family Physician, February 1995, 
Vol. 51 (2), pp. 429-31. 

Robert Cushman, Injury Prevention: The Time Has Come, 
Can. Med. Assoc., January 1995, Vol. 152 (1), pp. 21-3. 

Committee on Injury and Poison Prevention, Office-Based 
Counseling for Injury Prevention, Pediatrics, October 1994, 
Vol. 94 (4), pp. 556-7. 

Kelly Overhaugh, The Adolescent Athlete, Part II: Injury 
Patterns and Prevention Journal of Pediatric Health Care, 
September-October, 1 994, Vol. 8 (5), pp. 203-1 1 . □ 




atient surveys make it clear. Your patients want to know more 
about their medicines, e.g., how and when to take them, for how 
long, precautions and side effects. Don't disappoint them. 

The National Council on Patient Information 
and Education (NCPIE) has free materials 
to help you "Communicate Before You 
Medicate." 

Write to: NCPIE 

666 Eleventh Street, NW 
Suite 8 10 D 
Washington, DC 20001 

To fax your request — (202) 638-0773 



TZju^^^ 







90 



NCMJ March/April 1996, Volume 57, Number 2 




fANOPERAnON 

That'u Make 
You Feel Better 



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CLINICAL COMMUNICATION 



Behind the Surgery Doors 

A Look at What English General Practitioners Do 

Francis A. Neelon, MD 



Medical practice in the United States is, as everyone knows, 
changing rapidly. The forces driving change derive less from 
dissatisfaction with the quality or kind of care available (al- 
though those factors play some role) and more from society- 
wide economic concern about the costs of intensive treatment 
of disease. One result of this change in practice is that US 
doctors are trying to increase their "throughput" and "effi- 
ciency" (that is, see more patients per hour) by using brief, 
focused patient encounters, rather than the all-encompassing, 
system-reviewing, multiple-problem health exam I had been 
taught to consider the ideal. 

To be sure, many American doctors have run brief-encoun- 
ter practices, but virtually all English general practitioners 
(GPs) have. For example, Byrne and Long' noted that the entire 
duration of 74 GP consultations ranged from 1.6 to 14.8 
minutes, with a mean of 4.7 minutes. And Balint and Norell 
titled their book 5a Minutes for the Patient^ because that was 
the time that they reckoned the average GP had with the patient. 
I wanted to see what GPs got done in five or six minutes with 
the patient and contrast that with the general internal medicine 
practice I have known. 



What I Did in England 

In early May 1994, through the good offices of Dr. John Lister 
to whom I had been introduced by the late Dr. Eugene Mayer of 
Chapel Hill, I went to England to meet, individually, with 
several general practitioners and to observe each at work in his 
surgery (office). I did not want to read about what GPs did or 
hear them tell about what they thought they did; 1 wanted to see 
with my own eyes and to formulate what they were doing for 
myself. I hoped to be able to form an opinion about their 



Dr. Neelon is Jouma/ Editor, and Associate Professor, Depart- 
ment of Medicine, Dul<e University Medical Center, Durham.This 
project was supported by a grant from the Mary Duke BIddle 
Foundation. 



conception of "the doctor's job" by reasoning backward from 
the behaviors I saw. 

Dr. Lister, through the offices of the Royal College of 
General Practitioners, arranged for half-day visits to the surger- 
ies of five GPs — two in London, one in Beaconsfield, a London 
subiu'b, and two in Exeter in southwest England. Since I visited 
only five practices in only 10 days, my sample cannot be taken 
to represent the universal state of medical practice in England. 
But what I saw was quite consistent from doctor to doctor, and 
the images and impressions I formed were quite striking. 

1 was allowed to sit (as unobtrusively as possible) in the 
surgery during sequential patient visits. I did not participate in 
any direct way; I watched the interaction of doctor and patient, 
made brief notes about each encounter, and timed the duration 
of each. I made one house call (with Dr. Sweeney, in Exeter). 
I also learned about contemporary English general practice by 
talking with each of the GPs outside their surgery hours, with 
Dr. Lister, with Mr. Malcolm Sharp, a consulting otolaryngolo- 
gist, and with Professor Charles Easmon, postgraduate dean for 
the North Thames West district. I also was able to attend a one- 
day symposium on the doctor-patient relationship titled "Re- 
capture the Joy of General Practice," sponsored by the Balint 
Society. I present here my observations about and reflections 
on: the duration of GP consultation; the structure of the consul- 
tation; the reasons patients visit the GP; the nature of the GP's 
examination of the patient; an evaluation of the encounter 
between doctor and patient; the organization of general prac- 
tice; and the new economics of general practice. 



In the GPs' Surgery 

The Duration ofConsultation. I had the opportunity to observe 
46 encounters by GPs, involving 49 patients. In one instance a 
mother discussed the problems of the two children she brought 
with her, and in another, the doctor sequentially looked at all 
three members of a non English-speaking Turkish family. All 
of the doctors told me that they scheduled consultations every 
10 minutes (no longer every five or six). Of course, some visits 



92 



NCMJ March/April 1996, Volume 57 Number 2 



(say, a prescription refill) are very brief, while some ran 20 
minutes or longer. I recorded the length of time each doctor 
spent with each patient (rounded to the nearest minute); 
the average duration of the 46 encounters was 9.96±4.8 
minutes (mean±SD), with a median of 9.0 minutes and a 
range of two to 23 minutes (interestingly, the same doctor 
produced both extremes of the range). The duration of 
consultation was not symmetrically distributed but was 
skewed toward longer times around a modal value of eight 
minutes (Figure 1 , at right). Ninety-five percent of the 
consultations lasted between three to 20 minutes. 

The number of patients seen by each doctor varied 
considerably (Table 1, below). In part, this was the result 
of some doctors "lightening" their caseloads in order to 
have time between consultations to talk to me (since we 
did not speak or interact in any professional way during the 
consultation). Still, there was aclear pattern to the duration 
of consultations as shown in Table 1 . The average duration 
for four doctors (A, C, D, and E) was 10.8±4.9 minutes in 
average diu"ation of consultation. These doctors did not 
differ statistically from one another (Table 1 ), although the 
average duration for Dr. C (which was the longest average 
of the group) approached statistical significance. 

In contrast, the oldest of the doctors I visited and the 
one longest in practice (Dr. B) had an average consultation 
duration of 6.3 minutes. This was significantly shorter 
than the other four physicians' (Table 1). Direct compari- 
son of each doctor's average duration of consultation with 
each other doctor's (Table 2, next page) confirmed these 




4to6 7to9 101012 13to15 I6I0I8 19to23 
duration of consultation (mins) 

Figure 1 : Frequency distribution of consultation duration. 



results: Dr. B's (and only Dr. B's) consultations differed signifi- 
cantly (briefer) from the other doctors. I speculate that this represents 
a continuation of the practice of briefer visits scheduled by an earlier 
generation of GPs. 



Table 1. 


Characteristics of consultations by five GPs 






Doctor 


Number of 
patients seen 


Duration of 
consultation by 
individual doctor 


Duration of 
consultation by 
other four doctors 


Significance* 


A 


3 


Mean±SD 

Median 

Range 


11.3±3.1 mins 
12.0 mins 
8 - 14 mins 


9.914.9 mins 
9.0 mins 


p=.50 
p=.40 


B 


9 


Mean±SD 

Median 

Range 


6.3±2.1 mins 
6.0 mins 
3-10 mins 


10.814.9 mins 
11.8 mins 


p<.001 
p=.007 


C 


17 


MeaniSD 

Median 

Range 


1 1 .9±6.2 mins 
10.0 mins 
2 - 23 mins 


8.813.5 mins 
8.0 mins 


p=.07 
p=.13 


D 


10 


MeaniSD 

Median 

Range 


10.1±3.4 mins 
11.0 mins 
4- 15 mins 


9.9+5.2 mins 
8.0 mins 


p=.90 
p=.59 


E 


7 


Mean±SD 
Median 
Range . 


9.1+3.9 mins 
8.0 mins 
4- 14 mins 


10.115.0 mins 
9.0 mins 


p=.58 
p=.79 


'Significance of differences in duration of consultation by individual doctors compared to the four peers (combined) using Student's t-test 
(witfiout assuming equal variances) to compare means and the Mann-Whitney test to compare medians. 



NCMJ March! April 1996. Volume 57 Number 2 



93 



Doctor A 



Doctor B 



Doctor C 



Doctor D 



Doctor B 

t p=.09* 
wp=.04* 



The Structure of the Consultation. 
Byme and Long proposed six com- 
ponent parts to the GP consultation 
(Table 3, alright), al though notevery 
encounter demonstrated all compo- 
nents. My observations were quite 
consistent with the Byrne-Long 
model, but I did not tape-record the 
encounters and so cannot make a 
definitive statement about all aspects. 
In only two instances were the pa- 
tients new to the doctor, and so for 
most visits, a clearly obvious rela- 
tionship had already been established; 
most doctors alluded to (and thus 
reactivated) the relationship in some 
way — asking about family members, 
inquiring about holiday plans or work 

conditions. There was no doubt: these doctors knew their patients 
well and had a strong professional relationship with them. 

The Reasons for Visiting the GP. In every instance the GP uncovered 
some plausible reason for the visit (Table 4, below), in some cases 
more than one reason. For instance, in one consultation a mother 
discussed the serious health problems of her three-year-old son with 
diabetes and her six-year-old with asthma; in another instance, the 
doctor labored valiantly to sort out the reason(s) for the visit of a 
Turkish-speaking immigrant family of three, accompanied by a 
brother (the translator) who spoke only a few words of broken 
English. The mother was pregnant (the 
doctor tried to address that obvious con- 
dition, but that was not the reason for the 
visit) and asthmatic (she was given a 
prescription for a metcred-dose inhaler); 
the husband lifted his shirt to reveal a 
nummular eczema (he was given a ste- 
roid cream); finally, the brother got across 
that the two-year-old son (with a runny 
nose) had a cough. After 23 minutes, the 
doctor asked all to return later when a 
bona fide interpreter would be available. 
Overall, I thought that the doctors 
uncovered the right problems and took 
appropriate action. Of course, there was 
no way to ascertain that the oven reason 
for the consultation was \ht fundamental 
reason.' In one instance, a patient with 
known (and treated) bladder cancer com- 
plained of "tiredness" and early morning awakening. The 
doctor examined her for metastatic disease and sent her for 
hemoglobin measurement but did not explore the possibility of 
depression. On the other hand, in several instances, rather than 
stop with the overt symptomatic offering, the doctor continued 
to probe and thereby unearthed important underlying psycho- 
social problems (an unresolved grief reaction; a school phobia; 



Table 2. Do GPs differ from one another In duration of consultation? 



Doctor C 

t p=.82 
w p=.96 

t p=.003 
wp=.017 



Doctor D 

t p=.59 
wp=.61 

t p=.01 
w p=.02 

t p=.34 
w p=.69 



Doctor E 

t p=.39 
w p=.49 

tp=.12 
w p=.20 

t p=.21 
w p=.39 

tp=.61 
w p=.73 



'Significance of differences in duration of consultation by eacfi doctor (see Table 1 ) compared 
to each ottier individual doctor using Student's t-test witti no assumption of equal variances (t) 
to compare means and ttie Mann-Wfiitney test (w) to compare medians. 



Table 3. Structural elements of the consultation* 

1. Establish a relationship 

2. Discover the reason for the consultation 

3. Conduct a verbal or physical examination 

4. Consider the meaning of the information 

5. Outline the details of treatment 

6. Bring about closure 

*After Byrne and Long' 



Table 4. Reasons for visit to the GP 










Number* 


Joint complaints 




9 


Administrative help; advice; prescription 


renewal 


8 


Non-specific or psychosomatic complaints 


6 


Antenatal or well-baby check 




6 


Dermatological problems 




5 


Major psychiatric disorders 




4 


Asthma 




4 


Diabetes check 




3 


Upper respiratory infections, otitis 




2 


Intestinal disorders 




2 


Cancer 




2 


Heart disease 




2 


Transient ischemic attack ^ 




1 


•Numbers total 54 because sometimes more 


than one problem was 


the focus of a visit. 



a situational anxiety reaction; a driving phobia; and post- 
traumatic activation of underlying psychosis). 

The Examination of the Patient. The doctors always made (I 
thought) an appropriate verbal examination of the patient 
(although with the Turkish family described above, this was an 
adventure of uncertain outcome) . The diagnostic and therapeu- 



94 



NCMJ March/ April 1996, Volume 57 Number 2 



tic outcomes of the encounters seemed quite appropriate. In 
contrast, physical examination occurred much less often 
(Table 5, at right) than I had anticipated from my US 
experience. In 37% of the encounters there was no physical 
examination at all and in another 9% examination, only an 
instrumental measurement (determination of peak expira- 
tory flow in two asthmatic patients, measurement of blood 
pressure in one patient, and ultrasound of the fetal heartbeat 
in one). There was no "routine" measurement of weight or 
"vital signs" as in this country. When measurement of 
weight was important (in one case), the doctor had the patient 
"just pop up on the scales." There was no evidence of an 
assistant or office nurse to take pulse or blood pressure; the 
doctor himself took the blood pressure if needed and called all 
patients into the examining room. 

I have no direct information about the interior consider- 
ation by the doctor of the clinical data he obtained (Table 3), but 
I was able to observe the details of treatment outlined and the 
closure of the visit. In general, these were always appropriate 
and carried out with quiet skill as a seamless part of the 
interaction. I have no quantitative evaluation of these elements, 
but I thought the plans made by these five GPs for treatment, 
further evaluation, referral, and return seemed just right I have 
not seen better. 



Table 5. Was a physical 


examination carried out? 


Limited physical exam 




25 visits (54%) 


No physical exam 




17 visits (37%) 


Instrumental check only (peak expiratory 
flow rate; blood pressure; fetal ultrasound) 


4 visits (9%) 



part identified by verbal exam (for example, palpating the 
abdomen in patients with belly pain, ausculting the lungs of 
asthmatics, examining aching hands or elbows). Because physi- 
cal examination took up so little of the visit, the doctors had time 
to (and did) explore psychosocial aspects of the history. In no 
instance (even with new patients) was there a "complete" or 
screening physical exam — the patient's complaint (overt or 
covert) provided the stimulus and guide to the whole consulta- 
tion. Some screening examinations are done (mammograms. 
Pap smears), but they are the purview of a district agency or a 
practice nurse rather than being incorporated into an office visit. 
When a physical exam was done patients did not disrobe 
fully and did not put on gowns— the shirt was lifted or the 
^^^___^^^^^ blouse loosened. When drap- 



An Evaluation of the Encoun- 
ter. Much of what happened 
between these doctors and 
their patients seemed very fa- 
miliar."-' The nature of the 

complaints, the reactions of 

patients, the presentation of psychosocial problems in the guise 
of symptomatic complaints, the behavior of the doctors, looked 
to me like what I see in this country. None of this was alien. Only 
once was the language itself a problem (a mentally retarded man 
mumbled, and with a thick Scots accent). The doctors seemed 
genuinely interested in their work and their patients. 

I thought that the consultations were efficient and unhur- 
ried, despite their brevity. In part this was because the patient's 
complaint set the agenda for the entire visit. On two occasions 
patients returned to follow up a visit made a day or two before 
(to be sure that the identified problem was resolving), but there 
were no other doctor-driven appointments. Nothing resembled 
the "yearly physical" so popular here. No doctor indulged in a 
generalized review of systems or a recapitulation of resolved or 
quiescent problems. No one seemed to be "looking for trouble" 
that was not causing the patient some distress. No doctor 
seemed worried that he might be "missing something" (and 
hence subject to a malpractice suit for "failure to diagnose," as 
in this country). 

In part, too, time was saved by limiting the physical 
examination. In more than a third of cases, there was no physical 
contact of doctor with patient at all (this also saved time 
otherwise needed for hand-washing and disrobing!). In all other 
cases, physical exam was limited to evaluation of the organ or 



No doctor seemed worried that he 

might be 'missing something' (and 

hence subject to a malpractice suit for 

'faiiure to diagnose' as in this country). 



ing was necessary, a blanket 
was used rather than a sheet 
and it was not changed for 
subsequent patients — a prac- 
tice that I suspect would raise 
eyebrows here. 



The Organization of General Practice 

The GPs I visited organized their practice in similar ways: they 
had a morning "surgery" that ran from 8:30 a.m. or 9 a.m. until 
about 1 1 a.m. with time for urgent or "work-in" patients before 
noon. There was an afternoon session from 3 p.m. or4 p.m. until 
6 p.m. On ordinary days (when no visitor from America was 
present), the doctors would see between 15 and 20 patients at 
each morning and afternoon session. Between the surgery hours 
the doctor had time for administrative duties or house calls. No 
doctor had a hospital practice, but the two I visited in Exeter 
were associated with the medical school there and were in- 
volved in teaching and in research. All of the doctors worked in 
group practices and shared night call in a rotating fashion. Since 
English patients can request a house call by their GP, all doctors 
lived in or near the district in which the practice was located. I 
was told that some GPs now contract night call coverage to 
commercial services, especially in inner-city districts where 
there has been an increase in criminal assault on night-covering 
doctors. 

The British GP has access to a number of social services 
provided by the socialized medical system: visiting nurses, 
home workers and aides, subsidized care and living facilities. 



NCMJ MarchI April 1996. Volume 57 Number 2 



95 



These services do provide GPs with considerable support for 
the outpatient care of their patients. Referrals to consultants or 
hospitals are usually made for clearly "medical" reasons than 
for social or economic problems. 

Since GPs run a purely outpatient practice, patients with 
serious medical problems are sent for diagnosis and treatment 
to specialist consultants, usually associated with hospitals. It 
had been the rule that patients diagnosed with serious chronic 
health problems continued to be followed by the specialist after 
diagnosis and treatment, but that is beginning to change. Now 
patients with common, relatively stable disorders such as dia- 
betes or asthma are sent back to the GP for continued care after 
diagnosis. As a result, several of the GPs I visited have orga- 
nized "specialty" clinics for long-term care of patients with 
diabetes or asthma. Usually a practice nurse is in charge, but a 
GP attends the weekly clinics devoted to patients with these 
disorders (I did not visit any of these disease-oriented clinics). 
This change from episodic, purely symptom-driven visits is 
relatively new and has necessitated some educational "re- 
tooling" by the GPs. 



Economics of the Practice Model 

The new concept of "fund-holding" is a recent change that is 
reshaping medical practice in England. Previously, separate 
funds were established each year by the government to pay for 
patient care by GPs and specialists. Once allocated, the funds 
available for these services were fixed, and there was no transfer 
from one "pot" of money to the other. As a result, a patient sent 
by the GP was turned over to the consultant and his services 
were paid for by the government. There was no financial 
interaction of consultant with the GP, and (so the GPs told me) 
consultants sometimes exhibited a degree of condescension and 
hauteur in their interactions with GPs. That has changed. Now, 
GP practices of a certain minimal size (about 20,000 patients), 
can elect to become fund-holding practices, which means that 
they are given a negotiated amount of money they use to pay for 
all aspects of care for their patients, including specialty care and 
consultation. If the practice stays within its budget, the saved 
funds can be used, not for personal purposes, but to enhance 
aspects of the practice (to improve physical facilities or to 
arrange for on-site specialty services such as visits to the 
practice by physical therapists, dermatologists, psychiatrists, 
and so forth). This maneuver has made GPs much more "cost- 
conscious," leading them to "shop" for the most timely, effec- 
tive and useful services for their patients. Consultants, for their 
part, have become more "user-friendly" in their interactions 
with the referring GPs (because if they don't provide good 
service, they don 't get more referrals). The government sees the 
GP as putting a brake on wasteful — or at least unconsidered — 
exf)enditure of funds. It still too soon to know how fund-holding 
will play out, but it has clearly given a sense of empowerment 
to the GPs I visited — and sent a sense of alarm through the 
consultants who fear that subspecialty training may be compro- 



mised by the need to cater to referrals and to run mini-clinics in 
GPs' offices rather than large teaching clinics at hospitals. On 
balance, though, and looking at things largely from the perspec- 
tive of the GP, I was impressed that this administrative ploy had 
blown a breath of invigorating fresh air into the GPs' surgery. 

GPs (in 1994) told me that they earned the equivalent of 
about $60,0(X) a year in a country where the cost of Uving seems 
similar to the US. To earn his salary, each GP provides care to 
about 2,000 patients on his "list." There is a merit system which 
can increase the doctor's earnings, but relatively modesdy — 
and only about one-third qualify for this; some GPs supplement 
their income by seeing private patients. Consultant specialists 
make more — probably in the range of $100,(X)0 a year — but 
none get rich the way that some US specialists have. 

Some doctors enter general practice because they cannot 
wait out the long training for (or despair of getting) an appoint- 
ment as a consultant, but the chief reason — certainly for the 
doctors I visited — seems to me to be a real joy in interacting 
with people and the ability to make a profound difference in 
some rather ordinary lives in an intimate, caring way. All the 
doctors I met radiated real pleasure and pride in their work. 



What I Learned in England 

I was curious to find out if GPs could really get through a 
consultation in five or six minutes (as I had read), and to find out 
how they did it. I had expected that inquiry about psychosocial 
matters would be minimized (since most doctors in this country 
seem to feel that opening that Pandora's box leads to loss of all 
time control in the clinic). In contrast to my expectations, the 
doctors I visited actually spent about 10 minutes per visit and 
they thought this was the modem norm. I was surprised (and 
heartened) to find that discussion of psychosocial matters 
occupied a good deal of the consultation, sometimes the domi- 
nant portion. Possibly this is a reflection of the continuing 
influence of Michael Balint* whose pioneering work clearly 
defined the po^X-erful therapeutic role of the GP and gave honor 
to those doctors who wanted to learn how to really help the 
patients who came to them. I was surprised, too, to see how 
often physical examination was dispensed with. It was often 
absent and always limited, thus saving a great deal of time that 
could be (and was, I thought) put to better use. In this country, 
I find clinic note after clinic note filled with redundant or 
unnecessary physical examination data. I have also been struck 
by how often resident physicians I have been supervising begin 
a physical exam in order to stop their patients from talking about 
some item of psychological significance ("open wide and stick 
your tongue out"); the English GPs did the opposite, encourag- 
ing their patients to talk and avoiding the interruption of ritual 
physical exam. 

Even more time was saved in recordkeeping. By American 
standards, GP notes are almost invisible — one or two lines 
hand-scribbled on a card. These doctors, of course, have the 
advantage of living amid their patients, of having been in their 



96 



NCMJ March/April 1996, Volume 57 Number 2 



homes on sick-call, of knowing their families, their bosses, their 
pastors. I doubt that the GPs' records would do a lot of good in 
defense of a US malpractice suit, but that is not a problem for 
English GPs (at least at the moment, although there is a 
developing trend toward litigiousness). 

Finally, I was struck by the absence of a nurse or assistant. 
There were secretaries and file clerks, and someone to draw the 
patients' blood, but the doctor himself called patients into the 
surgery, and took "vital signs" when they (rarely) were needed. 
On the other hand, the four youngest of the doctors I visited all 
had computers on their desks — and used them. The computers 
listed the patients' medications (and were able to print out refill 
prescriptions!); records of immunizations. Pap smears and 
mammograms; and certain administrative data. When one 
patient was worried that her "high blood pressure" would 
prevent her long-awaited and much-needed hip replacement 
surgery, the doctor reassured her by printing out and giving her 
a graph of her blood pressure results for the past several visits. 

1 felt quite at home in the presence of these doctors. The 
level of their attention to a variety of problems was very good 
and the advice they dispensed, excellent. I could have slipped 
behind the doctor's desk and felt at ease (although I would have 
had to learn a good deal about the workings of referral agen- 
cies). Medically, they and I seemed to be on the same wave- 
length. Their morning "surgeries" reminded me of my time in 
the urgent care clinic here, seeing patients who were provoked 
into visit by some present worry or symptom — except that they 
were like urgent care clinics in which the doctor already knew 
each patient well. 

My visit was great fun. It has made me look again at what 
I do — the "check-up," the "review of systems," the "screening 
physical" — and at the cost (in time) they extract. It made me see 
again the real reason behind the meeting of doctor and patient. 
Balint said it best when he wrote: "the most frequenUy used 
drug in general practice was the doctor himself, i.e. that it was 
not only the bottle of medicine or the box of pills that mattered, 
but the way the doctor gave them to his patient — in fact, the 
whole atmosphere in which the drug was given and taken."' □ 



References 

1 Byrne PS, Long BEL. Doctors Talking to Patients. London: Her 
Majesty's Stationery Office, 1976. 

2 Balint E, Norell JS. Six Minutes for the Patient. London: Tavistock 
Publications, 1973. 

3 Howell WH. The content of one doctor's practice: relevance of the 
biopsychosocial model. NC Med J 1992;53:404-9. 

4 Bumum JF. What one internist does in his practice: implications for 
the intemist's disputed role and education. Ann IntMed 1 973 ;78:437- 
44. 

5 Brody BL, Stokes J III. Use of professional time by internists and 
general practitioners in group and solo practice. Ann Int Med 
1970;73:741-9. 

6 Balint M. The Doctor, His Patient, and the Illness, revised edition. 
New York: International Universities Press, 1972. 



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CLINICAL COMMUNICATION 



The Doctor-Patient Relationship 

Behavioral Aspects of an Unequal Partnership 

Gertrude Blanck, PhD 



In the course of their busy workday, doctors tend to focus on the 
problem each patient presents for treatment. They may over- 
look the patient's behavior unless it interferes with the purpose 
of arriving at a diagnosis and prescribing treaUnent. Neverthe- 
less, patient behavior is always a part of the interaction and may, 
on occasion, be an obstacle to good care. In this communication 
I attempt to explain why patients sometimes behave in difficult 
and often irrational ways, and to suggest how the physician may 
deal with, perhaps even prevent, such behaviors. 

Many factors influence the patient's ability to cooperate, to 
provide history, to tolerate the examination, and to accept the 
diagnosis and treatment. The best known of these factors are the 
patient's intelligence and educational level. Doctors recognize 
that they must modify their communications to accord with the 
patient's intellectual ability to understand. These are important 
elements of the doctor-patient interaction, but I want to focus in 
this paper on some less-known psychological factors. 

Let's assume that doctors, being healthy, arrive at their 
consultation rooms at a peak level of functioning, ready for the 
day's work. Patients, unless there for preventive care, arrive in 
quite a different condition. They have a complaint. Some part 
of the body is not functioning well. They may be in pain. They 
always have concerns. Every patient, no matter how calm in 
appearance, is under stress when entering the consultation 
room. Inequality is built into the encounter between a healthy 
doctor and an ailing and anxious patient. Therefore, the patient' s 
ability to cooperate and to process information tends to be 
impaired to varying degrees. Furthermore, patients use a variety 
of psychological mechanisms to deal with their stress and 
uncertainty: 



Dr. Blanck teaches at the Duke-UNC Psychoanalytic Institute. 
She is the author of five texts on psychotherapy and numerous 
papers in psychoanalytic journals. She taught and practiced in 
New York City and lectured worldwide before moving to North 
Carolina. 



Denial is a common way of dealing with unpleasant situations. 
Especially when the diagnosis and prognosis are unfavorable, 
patients may not hear what the doctor says. They may nod their 
heads, but not comprehend. Doctors need to be aware that their 
having spoken is not the equivalent of having been heard. A 
doctor may offer a most painstaking explanation, only to find 
later that the patient has not heard or has "forgotten" everything. 
Some patients take notes. It has even been suggested that 
patients use a tape recorder but that, I believe, constitutes an 
unwelcome intrusion and impairs the spontaneity of exchange. 
A possible solution is to have a nurse or social worker review 
the plan with the patient, especially if compliance is crucial to 
the outcome of the treatment. For the intellectual patient, 
reference to the literature might be more satisfying than at- 
tempting to engage in time-consuming explanation. Other 
factors to which the physician needs to be attuned are transfer- 
ence, anxiety, regression, resistance, and dependency. 

Transference refers to the characteristic way that one person 
deals with another. We establish the patterns of how we relate 
early in life within our primary families, and we carry those 
patterns into all future relationships, modifying them somewhat 
as we go along. Well-adjusted adults learn to deal with the 
expanded world outside the family by flexibly altering their 
patterns of behavior to conform with new situations. Less well- 
adjusted persons remain rigidly fixed in inappropriate modes of 
relating that may render them unable to recognize the unique- 
ness of the doctor's personality. They deal with the doctor (and 
others) in patterned, stereotyped ways that derive from child- 
hood. Of course, the actual behaviors cover a broad spectrum 
and I cannot describe them in every manifestation. But it is 
helpful for doctors to know about transference in a broad way 
so that inappropriate patient behavior will be less puzzhng, and 
especially so that the doctor will feel more comfortable with 
difficult patients. 

Take, for example, a patient who has been under continu- 
ous treatment for an infection but has not gotten well despite 
taking a number of antibiotics. The first question likely to enter 



98 



NCMJ MarchI April 1996, Volume 57 Number 2 



the doctor's mind is whether the patient has followed instruc- 
tions accurately. If the doctor actually asks that question, there 
may be an inappropriate outburst, the patient blaming the doctor 
for not having come up with "the right antibiotic" quickly 
enough. There is immediate conflict between doctor and pa- 
tient. Each blames the other, although the doctor may keep quiet 
in order to avoid open conflict. That is the correct approach. 
Otto Fenichel, a noted psychoanalytic theorist, suggested that 
doctors avoid "playing the game," because the patient is not 
dealing with the reality of the moment, but reenacting old 
conflicts or recreating earlier experiences of not being helped 
when in distress. The unspoken feeling behind the outburst is: 
"You don't care enough to help me." In reality, the doctor may 
indeed be caring and truly trying to find an answer for the 
patient's condition. The doctor may find it bizarre that the 
patient does not recognize this, but by not "playing the game" 
the doctor avoids becoming a partner in the patient's reliving of 
the past. Often this will defuse the situation because the doctor 
does not join in the replay. 

Transference is ubiquitous and doctors experience it, too. 
Their feelings are influenced by their forgotten pasts. The 
doctor may "like" or "dislike" a patient, not because of how the 
patient acts but because of irrelevant criteria buried deep in the 
doctor's personality. Perhaps the patient displays some behav- 
ioral characteristic that the doctor disliked long ago, or reminds 
the doctor of some adversary from the past. That is not to say 
that doctors must like patients who become irritable and de- 
manding while the doctor is working in their behalf, but it is 
important to avoid allowing dislike to get in the way. That is 
difficult. In the course of a day's work doctors will see some 
patients who are gratifying and some who are not. Chalk it up 
to transference and hope that the gratifying interactions over- 
ride the others. 

Anxiety is also always present in every doctor-patient encoun- 
ter. Sometimes it is the doctor who is anxious. No matter how 
mature we are in most respects, anxiety colors the way patients 
and doctors behave in the consultation room. It may even impair 
the ability to relate appropriately. A famous psychiatrist of 
another era. Dr. Robert Knight, tells of observing a session 
between a patient and resident at Austin Riggs Hospital. Both 
parties exhibited signs of anxiety. Dr. Knight wondered to 
himself, "Which one is the doctor and which is the patient?" 
"Oh yes, of course," he answered himself silently, "the one in 
the white coat is the doctor." 

The most common physical manifestation of anxiety is the 
well-known elevation of blood pressure. The blood pressure 
reading does not measure anxiety accurately, but it does verify 
that it exists. Of course, it is quite possible that an anxious 
patient will have a normal blood pressure. That is why poly- 
graph tests, so prized by lawyers, are not reliable. 

What should one do about an anxious patient? First we 
must realize that the patient's behavior is unique to this particu- 
lar situation (unless the presenting complaint is pervasive 
anxiety). A knowledge of the special nature (and the inequality) 



of the doctor-patient encounter lets the doctor understand why 
the situation is uncomfortable for the patient. It helps to be 
reassuring wherever this can be done without falsifying the 
truth about the illness. Calmness and a true statement of the 
prognosis can go a long way. "We will take care of that," is a 
useful phrase even when the doctor cannot assure that all will 
be well. It does not promise too much, yet the "we" enlists the 
patient's participation in whatever can be done. The patient is 
left feeling part of the team. 

What if it is the doctor who is anxious? Sometimes this 
happens when the patient has a baffling, even fi-ustrating 
problem . All of us are most comfortable when we know what to 
do, but that is not always possible. It is hard to live with 
uncertainty even though it is a fact of life. Take, for example, the 
patient who handles anxiety by becoming authoritative: "You 
must do something about this now." The doctor needs time to 
think and is deflected by feeling rushed. If the patient is older 
than the doctor, the encounter can bring back memories of an 
authoritative parent or teacher (more transference!). It can be 
helpful for the doctor to know that the patient is not really 
delivering an ultimatum that has to be obeyed; the behavior is 
a manifestation of the patient's own anxiety. Doctors grow up 
trying to know as much as possible. It can attenuate anxiety to 
realize that one cannot always know. Learning to Uve with 
uncertainty can be difficult at times; it can even be humbling. 
Somewhat paradoxically, it can also be reassuring to feel that 
we do not have to appear omniscient. 

Regression is a less easily recognized phenomenon. It is, in fact, 
a part of transference. It represents reversion to an early form of 
neediness at the time the boundaries of parental care were 
established, and is best recognized by a doctor who knows the 
patient well, has seen him or her at different times, under 
different degrees of stress, and therefore at different levels of 
regression. Although the desirability of continuity of care is not 
arguable, we often find care dispensed by a succession of 
strangers. A doctor exposed to new patients every day cannot 
know the degree of regression, but may assume that it exists. It 
may take the form of failure to offer pertinent features of the 
history , or of describing symptoms inaccurately , or of including 
"red herrings" that cloud the doctor's ability to assess the 
situation. Patients who were competently cared for as children 
are less likely to regress to the point that they question the 
doctor's competence and do not comply with treatment. 

How should doctors deal with the inevitable regression that 
occurs in the unequal partnership? Doctors may assume that 
patients are capable of a higher degree of functioning than they 
demonstrate in the immediacy of the encounter. It is a mistake 
to assume that a patient cannot cooperate merely because he or 
she appears helpless at the moment. Take the position, "You can 
do what I am recommending even though you do not feel this 
way right now." It gives a doctor a lift to find, on a return visit, 
that the patient has complied to a greater degree than would 
have been predicted by the helpless-appearing behavior of the 
moment. 



NCMJ MarchJ April 1996. Volume 57 Number 2 



99 



Resistance — an unwillingness to accept and cooperate in treat- 
ment — arises out of mistrust and is hardly ever deliberate. It is 
not a true reflection of the doctor's competence, but rather a 
signal of the patient's past experiences. Many patients feel that 
their previous care was insufficient or indifferent. Those who 
feel that they have been cared for inadequately may develop 
skeptical, or doubting, or even belligerent personalities. The 
patient who is oppositional, belligerent, even denigrating, is 
asserting a kind of misguided autonomy and independence to 
counteract pervasive feelings of dependency and helplessness. 
Such a turn of events makes the visit difficult for the doctor who 
would understandably prefer to have things go differently. It is 
helpful for doctors to remember that the troublesome patient is 
not truly assaulting the doctor as a person, only trying to assert 
a wavering autonomy. It is a relic of the patient's past and the 
feeling that "I have to take charge because no one else cares." 
A child is inexperienced and takes charge in inappropriate 
ways. The difficulty comes when the child's behavior takes on 
a rigidly patterned form that does not alter in adulthood. As 
professionals, we have to train ourselves to let the slings and 
arrows pass us by. This in no way implies that rude behavior is 
to be tolerated. Unruly patients have to be calmed down and 
forced to be polite; we want to understand, but need not tolerate 
unpleasant behavior. 

A more morbid form of resistance is found in patients who 
are secretly distrustful, who comply superficially but sabotage 
the treatment. The doctor may have no clue as to what is 
happening. This psychological quirk arises from totally mis- 
taken premises. Although paradoxical, the patient who has 
come "for help" is oppositional because of an automatic as- 
sumption that the doctor is an enemy. It is useful to keep in mind 
that this is no reflection on the doctor, only on the patient's past. 
If the patient fails to improve despite appropriate treatment, the 
doctor should consider whether the patient is an "opposer." 
Perhaps this is what happened to the patient I mentioned earlier 
who did not get well despite "appropriate" antibiotics. 

Dependency is the final aspect of the doctor-patient encounter 
that I want to discuss. No doctor can spend all day with a patient 
who wants, figuratively, to sit in his or her lap. That would not 
be useful in any sense. Some doctors learn to end a visit by 
writing a prescription. I do not think this is a good device. 
Compliance is best assured if the prescription is written and 
explained before the end of the visit. The very explanation thus 
becomes part of the treatment, psychologically. Another device 
is to leave the patient with a nurse, resident, or physician's 
assistant. If that course is chosen, it is essential that the doctor 
take proper leave of the patient. Leaving the room never to 
return deprives patients of the sense of closure necessary to 
make them feel that the visit was worthwhile. It is important to 
guard the future of the relationship by courteous behavior on 
both sides. When a patient lingers, a firm statement such as: 
"That is as much as we can do today. I'll see you next week," 
delivers the message nicely that the visit is over. 



Final Thoughts 

How does it help doctors to know about the silent and invisible 
features of the doctor-patient relationship? Doctors are usually 
aware of them in some form, but it is always useful to reconsider 
their existence and the fact that patients seen in the consultation 
room are rarely functioning at an optimal level. The doctor- 
patient encounter is invariably influenced by subtle shadings of 
the broadly outlined descriptions of denial, transference, anxi- 
ety, regression, resistance, and dependency I have given here. 
It helps to know that the psychological phenomena I have 
discussed have been observed, categorized, and labeled by 
menial health professionals who deal with them daily. In 
psychotherapy, these matters are at the very heart of the treat- 
ment process; in medicine they are just as important, but often 
unrecognized. They exert a silent but powerful and pervasive 
influence, sometimes affecting the very course of evaluation 
and treatment. Doctors who understand these factors add a 
dimension to their practices that makes each patient encounter 
more enjoyable. □ 



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100 



NCMJ March/April 1996, Volume 57 Number 2 




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FIRST-PERSON PHYSICIAN 



An Open Letter to My Grandchildren 



Thad B. Wester, MD 



Editor's note: In lieu of a 

traditional speech, Dr. Thad 
Wester read the following let- 
ter to North Carolina Medical 
Society members during his 
farewell presidential remarks 
at the NCMS Annual Meet- 
ing in Pinehurst on Novem- 
ber 11, 1995. 

He wrote the letter to 
conclude his autobiography- 
in-progress, chronicling his 
pre-medical school days un- 
til the present, which he in- 
tends to present to his grand- 
children. His words express 
what hefeels his family might 
learn about the medical pro- 
fessionfrom his own personal 
journey. 

We hope to stimulate 
discourse among our read- 
ers by reprinting an adapted 
version of Dr. Wester's letter 
here. His remarks struck us 
as especially provocative 
within the context of the se- 
ries of articles on managed 
care and health care reform 
covered in this — and planned 
for future — Journal issues. 



Dr. Wester was 1995 NCMS 
President. His address is 
P.O. Box 3126, Bald Head 
Island 28461. 



Dear Grandchildren: 

Your grandfather spent 30 years as a pediatrician in Lumberton, another 1 1 as a state 
and local public health official, and finally, a year as president of the North Carolina 
Medical Society. I want to focus here on my special journey in the profession and on 
my observations about that journey. The chronicle itself spans a time from an era of 
relatively low-tech medicine to one of increasing technical sophistication. This letter, 
for what it is worth, reflects my personal views about the medical profession. 

First, medicine is a challenging career. The personal and emotional commitments 
it demands have no equal in another profession or vocation. The commitments often, 
even usually, extend to those closest to you — family, friends, the people you work with. 
It is virtually impossible to practice medicine on an "island." It is the involvement and 
support of those closest to the doctor that allow competence to mingle with caring, 
compassion, and respect — the most valuable attributes in patient care. It is impossible 
to overstate the contribution of those who support our work. 

Second, medicine is now and has been a locus of change. How sad if the practice 
of medicine today had not changed from the beginning of my journey. We would still 
be treating children — vibrant young children like you — in "iron lungs" because of 
polio. Measles and mumps would still be a sometimes risky part of growing up. The 
death rate for infants would still be five times higher than it now is, and injury would 
still claim far too many lives and cause too much disability and suffering. I remember 
so many of those unfortunate ones from my early days in practice. This country can 
provide the best of medicine because of medical science's relentless drive for change 
and improvement. You will live longer and better lives because of these changes and 
improvements. 

But alas, not all change is welcome. Even as I write this letter, a great debate rages 
about how to provide medical care to everyone and at reasonable cost. Wouldn't you 
think that the richest country in the world would find this is a reasonable goal? 

It appears that cataclysmic and fundamental changes in the financing of medical 
care are coming. These changes are unsettling to many but certainly to doctors, nurses, 
hospitals, and others who provide care to patients. You might ask why this bothers us 
caregivers. Of several reasons, two certainly stand out: 

One, some doctors, some hospitals, some nurses, and others will not fare well when 
the financing of medical care is changed. The particularly bad part of this is that most 



102 



NCMJ March/April 1996, Volume 57 Number 2 



of them are good people who provide good care. They will 
be victims of change in the financial shifts of medicine. So 
will their families. 

Two, we are concerned about our patients. There are 
indications that the motives driving the change-makers are 
selfish and opportunistic. If so, for the first time in memory 
our profession will not be focused on the best interests of 
our patients. Some resources that might provide the right 
care for patients will be sacrificed to the profits needed to 
attract investors to the new enterprise. These are alarming 
conditions that could destroy the very essence of our 
medical care system. For your sake, we must not let that 
happen! 

Another of my observations relates to the lack of 
concern people have for their own health. Many folks — 
yes, you too, dear grandchildren — seem to lack the com- 
mitment to look after themselves. It is truly sad that so 
many of us don'teat the right things, don'texercise the way 
we should, don't do simple things to protect us from injury. 
Simple things — like wearing seat belts, avoiding tobacco, 
and being careful not to abuse alcohol and other drugs. 
Almost half the citizens of this country die sooner than they 
should because of unhealthy lifestyles. Somehow people 
have the notion that such things don't matter because, 
whatever the consequences, they can be fixed. True, we do 
a remarkably good job at fixing those problems, but at great 
cost in dollars and health. 

Let me tell you a story that a good friend shared with 
me. I hope that you will learn from this simple story. 
Certainly our society has not yet perceived the important 
lesson: There was a place in the mountains with a sharp 
curve in the road. Often drivers would not make it around 
the curve, but would fall off the mountain and get hurt. The 
people who lived in the area wanted to do something to help 
those folks who were getting hurt, so they built a first aid 
station at the bottom of the mountain. This helped, of 
course, but drivers came and came — and more and more 
drove off the cliff. The people's concern grew. They 
needed a larger and better facility and so they built one that 
attracted doctors and nurses skilled at treating people who 
drove off mountains. And the new facility was busy, with 
new trauma rooms and blood banks and laboratories. They 
bought CAT scanners and MRIs and doctors came to run 
them, and provided the very best in care to the people who 
drove off the mountain. 

Then one day a family rode through the mountains. 
The father proudly told his young child about the famous 
facility and the horrible problems it had solved. "But Dad," 
the child asked. "Why don't they just put up a strong, tall 
guardrail to keep the cars from falling off the mountain?" 

The last point I want to make concerns changes in the 



way some doctors behave. Unfortunately, not just doctors 
have changed — indeed our whole culture seems to have 
been altered in recent years — but I worry most about my 
own profession. 

I believe that being a physician is a great privilege and 
honor. We are asked to be a part of the most sacred 
relationship that can exist between people — to be trusted 
with another's life and well-being. In so doing, we and our 
patients and, indeed, all of society participate in an unwrit- 
ten contract based on trust That contract gives us privi- 
leges that few others get: respect, prestige, a good income, 
freedom to exercise professional judgment. In exchange, 
we are expected to do certain things: police our profession 
against incompetence, commit to lifelong continuous self- 
improvementand learning, and share our knowledge freely. 
We are accountable to higher ethical standards than others, 
and most important of all, we must place service to others 
above our own self-interest. 

When I went into practice, I believed that for the most 
part those ideals held. Now things have changed. This year 
I got a letter from a doctor who challenged us to protect his 
interest — his income against loss — because, as he wrote, 
"you are my union." We hear nowadays of medical scien- 
tists who focus on patent protection — not patient protec- 
tion — as they can7 out their medical research. Of course it 
is not a problem just with medicine. Recently, an attorney 
was accused of taking sexual advantage of a client. The 
issue was reviewed by the bar who concluded that he had 
done no wrong because there were no laws prohibiting 
such behavior. I have even heard of some clergy who are 
charging to counsel their "flock." How sad. How sad that 
this has happened to our learned professions, but saddest of 
all for physicians because of their special relationship with 
patients. 

Despite my somber review, I ask that you remember 
that most physicians do not fall in the selfish category but 
rather hold to the high principles of service. I want to 
encourage you, dear grandchildren, to think about becom- 
ing physicians too. Nowadays, every physician hears a 
familiar query: "Would you still invest the timeand energy 
to become a physician if you knew the changes you would 
face?" My answer is a strong and resounding "Yes!" It is 
true that I was privileged to live through the golden era of 
medicine, but it remains today and will be in the future, the 
most exciting, challenging, and rewarding work that I 
know of. There simply is no other profession that will 
afford you the opportunity to give so much and, in the 
process, to learn to understand others and their insights and 
their value to humanity. Nothing is more valuable or 
important than living a life with such a privilege. 

My love to each of you. □ 



NCMJ March/April 1996, Volume 57 Number 2 1 03 



The American Medical Association 
Organized Medical Staff Section 
(AMA OMSS) grew from the Hospital 
Medical Staff Section in response to 
special challenges facing physicians in 
managed care. It assists, represents, 
and unifies doctors in both managed 
care and hospital environments. 

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OMSS representatives discuss and initiate 
policy on issues including fairness and 
due process rights, continuous quality 
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leadership. The AMA OMSS also 
advances the advocacy and educational 
needs of physicians. 

Have a vote. 

Any medical staff of a hospital, 
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Each staff has one vote — an equal 
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Don't miss out. 

If you are interested in designating 
an AMA OMSS representative and/or 
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FIRST-PERSON PHYSICIAN 



HIV Myopia 



J. Trig Brown, MD, MPH 



It's the flu season and our office is swamped. Already we have 
filled our open appointments, adding so many that we are 
adding patients between added patients. This is going to be a 
very long day. 

The nurse says, "Dr. Brown, I've put another patient in the 
front treatment room. He looks pretty sick." In the jargon of our 
clinic, "...looks pretty sick" means "you better go see him 
now." I obey. 

I pull his thick chart from the wall rack. The name is 
unfamiliar; he is not a patient I have seen before. My pulse 
quickens and my jaw tightens as I read the first entry on his 
problem list: "HIV-positive." Having trained before the human 
immunodeficiency virus epidemic filled our teaching hospitals, 
I am always anxious about missing something important in 
these complicated patients. 

In the examining room, I acknowledge the patient's partner 
hovering near the stretcher. His furrowed brow speaks his 
concern. Glancing to the stretcher, I think to myself, "The nurse 
is right, this patient does look very sick." Lying in the fetal 
position, beads of sweat pour off his forehead. He wears a 
grimace and clutches his abdomen, resisting all movement. 
Tiny beads of sweat form on my brow. 

With a few questions I learn that he felt well until this 
morning when his belly started hurting. The pain peaked 
quickly. It is now incessant. No other historical clues help me 
narrow the long and growing list of diagnostic possibilities. 

I examine him more thoroughly than any medical student 
at the completion of the physical diagnosis course. I look over 
every inch of his body for clues. I probe every orifice, perform 
all maneuvers. I look at this optic fundi, structures far from the 
abdomen. Except for the rigid, quiet abdomen all is normal. 



Usually, after the physical examination, I know the likely 
destination of our diagnostic journey. Today, I am not certain, 
so many diagnoses seem possible. 

I send my patient to the laboratory for blood work and x- 
rays, and turn to see other patients. I cannot get this man out of 
my mind.. ..He looks like a patient with pancreatitis but he's on 
AZT, not DDI .... I wonder about erosive fungal esophagitis with 
perforation....lrememberacasereportonAIDScholangiopathy- 
— he fits this picture... .A passing colleague reminds me not to 
forget gastric lymphoma presenting with perforation.... 

At last, he's back from the lab: blood counts, urinalysis, 
liver function tests, and amylase are normal. I see no free air or 
pattern of intestinal obstruction on his abdominal film. To be 
certain, I transmit them to our off-site radiologist for an imme- 
diate reading. "Normal" comes the reply. 

I phone the general surgeon on call; he agrees to see the 
patient, but suggests first an abdominal ultrasound. Before long 
I am paged to the radiology department. The ultrasound shows 
a moderately large gallstone impacted in the neck of the 
gallbladder. Cholelithiasis! Probably would have been one of 
my first thoughts had I not known of this patient's HIV status. 
It set my course for the Isle of Esoterica, and I sailed blindly past 
the correct port 

I call the patient 24 hours after his laparoscopic cholecys- 
tectomy. He is at home, feeUng well and eating a light supper. 
"Thanks for all you did.... And Doc, thanks for treating me like 
a regular patient." 

"A regular patient?" I ask. 

"Yeah, some docs treat me differently when they find out 
I'm HIV-positive." □ 



Dr. Brown is Chief, Internal Medicine, The Carolina Permanente Medical Group, Durham-Chapel Hill Service Area, and Clinical 
Associate Professor, Department of Medicine, University of North Carolina at Chapel Hill. 



NCMJ March/April J 996, Volume 57 Number 2 



105 



PHYSICIANS' ROUNDTABLE 



Anesthesia for Neonatal Circumcision 

Is It state of the Art? 



Deputy Editor's note: We invite North Carolina physicians to comment on current controversies in medicine as part of our 
ongoing "Physicians' Roundtable." In this issue of the Journal, we consider the role of anesthesia in the circumcision of 
newborn boys. We asked a panel of North Carolina physicians to respond to the following query: 

Circumcision is the most common neonatal surgical procedure. Let us assume that circumcision has been chosen for 
a male infant. Some physicians say that the procedure causes intense pain and should be performed under local anesthesia. 
Others disagree or are neutral on this subject. What is your opinion? Do you think that anesthesia for neonatal circumcision 
is "state of the art"? What do you advise parents? 

The views of our panelists, listed alphabetically, follow. We invite Journal readers to comment by sending a letter to the 
Editor. — Edward C. Halperin, MD 



R. Meade Christian, Jr., MD, 
Ctiapel Hill Pediatrics 

I do not perform circumcisions myself but have been respon- 
sible for the follow-up of quite a few circumcised boys during 
the past 25 years. I will comment from that perspective rather 
than deal specifically with the issue of pain control. As with 
most operations, the operators' experience and careful attention 
to detail overshadow differences in technique. I believe this 
applies to the circumcision controversy. 

When the question of anesthesia for circumcision is raised 
during a prenatal consultation, 1 advise parents who choose 
circumcision to discuss the procedure with the person who will 
perform it. 1 advise them to look for evidence of the individual's 
experience and attention to detail. I think these are more 
important qualities to consider than the specifics of whether or 
not anesthesia is used. If, however, a skillful and careful 
operator offers a choice, 1 recommend choosing anesthesia. Q 



Caryn Hertz, MD, 
Department of Anesthesiology, 
Duke University Medical Center 

Infant boys have been circumcised for centuries. The procedure 
long predates modem anesthesia and can be done successfully 
without it. But those who have witnessed the surgery can attest 
to the fact that the infant displays distress both during the 
procedure and for the subsequent 24 to 48 hours. Recent 
biochemical blood studies confirm that infants have a stress 
response during circumcision without anesthesia just like that 
produced by any severe pain. This biochemical response can be 



tempered by use of local anesthetics. We thus have both 
subjective and object! ve evidence that infant male circumcision 
is painful. 

In deciding whether to use anesthesia for the procedure we 
must weigh benefits versus risks. The benefits include the 
avoidance of a stress response and the knowledge that the infant 
experiences no undue pain during a procedure that he can 
neither understand nor properly consent to. Good preemptive 
analgesia reduces the total pain response by preventing the 
initiation of a pain-hypersensitivity-pain cycle. Long-acting 
local anesthetics can prevent this pain cycle for several hours 
postoperatively, thereby improving patient comfort and per- 
haps reducing overall pain. On the other hand, the stress 
response is not severe enough to cause recognizable long-term 
morbidity or mortality; indeed most infants come through the 
experience without apparent repercussions. 

What are the risks of anesthesia itself? The risks of the 
currently popular penile block are those of introducing a needle 
and local anesthetic drug subcutaneously: infection; mechani- 
cal neural, or other tissue damage from the needle; and toxic 
reactions to the drug. The technique itself is easy to learn, and 
when done using proper sterile procedure, has little risk. Com- 
plication rates of 1% to 1 1% have been reported. The only re- 
ported complication is bruising at the injection site. No compli- 
cation was considered serious.''^ Those who witness infant 
circumcision with penile block confirm that the infant does not 
appear distressed. Methods using topical anesthesia (such as 
EML A cream — EMLA is an acronym for a eutectic [E] mixture 
[M] of local [L] anesthetics [A], lidocaine and prilocaine), 
which avoids the risks of needle placement, are being studied. 

As an anesthesiologist and the mother of three circumcised 



106 



NCMJ March/AprU1996, Volume 57 Number 2 



boys, (each of whom had dorsal penile blocks but with varying 
degrees of success), I firmly believe that the benefits of anesthe- 
sia for infant circumcision outweigh the risks. I also believe that 
infants, like others in society, deserve pain relief for elective 
surgery. 1 fully support its use now and our continuing research 
into the development of safer anesthesia techniques. □ 



William A. Nebel, MD, 

Chapel Hill Obstetrics 

and Gynecology 

Attempts to decrease the frequency with which "routine" cir- 
cumcision is requested have had little effect.^" The father's 
circumcision status and parental beliefs about the benefits of 
circumcision remain the important factors in determining the 
choice of this procedure.'' 

Circumcision is common in our country and therefore it is 
imperative to decrease the incidence of complications, many of 
which are preventable.' The use of penile dorsal nerve root 
block should make circumcision a painless procedure,* mean- 
ing the surgeon ought to be able to perform a rapid and non- 
traumatic procedure. That having been said, I do not believe that 
the long-term psychological benefits of anesthesia for neonatal 
male circumcision have been unequivocally demonstrated. □ 



Scott R. Schulman MD, FAAP, 

Depts. of Anesthesiology and Pediatrics, 

Duke University Medical Center 

Newborns are routinely circumcised without anesthesia. No 
other group of patients regularly undergoes surgery without 
anesthesia. Why do we continue to let neonates suffer? In part, 
because the difficulty in objectively assessing pain in neonates 
has led some individuals to conclude that neonates feel pain less 
than adults. This is not so! There is no reason to think that infants 
do not perceive pain. Furthermore, inadequate analgesia for 



circumcision can have adverse physiologic consequences' in- 
cluding: 1 ) increased secretion of the stress hormones epineph- 
rine and norepinephrine, which raise blood pressure; 2) de- 
creased transcutaneous oxygen tension; and 3) altered behav- 
ioral states.'" 

Dorsal penile nerve block (DPNB) is a safe, effective, 
economical, and easy-to-administer technique that is useful for 
alleviating the pain of newborn circumcision. A recent retro- 
spective review of 1 ,222 circumcisions performed under DPNB 
revealed a compUcation rate of 1.2%.' Complications were 
minor in nature with ecchymoses at the injection site being the 
most commonly observed problem. Prospective studies yield 
similar results.^ The cost of newborn circumcision is ^proxi- 
mately $152. At many hospitals this fee includes the infiltration 
of local anesthesia. 

Until recently, we did not know much about the pharmaco- 
kinetics and pharmacodynamics of analgesics and local anes- 
thetics in neonates. This lack of knowledge led to an exagger- 
ated fear of adverse effects from their use in neonates. Physi- 
cians were reticent to prescribe and administer pain-relieving 
medications to babies. But new information about the value of 
recognizing and treating pain in neonates is changing our 
attitudes and practices. We now have safe and effective ways to 
ameliorate the pain of newborn circumcision. These range from 
things as simple as letting the infant suck on a sucrose-flavored 
pacifier" or wine-impregnated gauze (as is the case in Jewish 
ritual circumcision) up to the use of local anesthetic block of the 
dorsal penile nerve,' or topical local anesthesia with EMLA 
cream.'^ 

Opponents of anesthesia for newborn circumcision con- 
tend that the procedure is so brief that the risk of local anesthesia 
exceeds the benefit A substantial body of recent data indicates 
that newborns do experience pain and that inadequate control of 
pain has deleterious physiologic and behavioral consequences. 
Since we now have a variety of safe, effective, and easy-to- 
administer ways to ameliorate the pain of newborn circumci- 
sion, our youngest patients deserve no less. Anesthesia for 
newborn circumcision is "state of the art" □ 



References 

1 Fontaine P, Dittbemer D, Schellema KE. The safety of dorsal 
penile nerve block for neonatal circumcision. J Fam Pract 
1994;39:243-8. 

2 Snellman LW, Stang HJ. Prospective evaluation of complications 
of dorsal penile nerve block for neonatal circumcision. Pediatrics 
1995;95:705-8. 

3 Herrera AJ, Hsu AS, Salcedo UT, et al. Role of parental informa- 
tion in the incidence of circumcision. Pediatrics 1982;70:597. 

4 Herrera AJ, Cochran B, Herrera A, et al. Parental information and 
circumcision in highly motivated couples with higher education. 
Pediatrics 1983;71:233. 

5 Lovell JE, Cox J. Maternal attitudes toward circumcision. J Fam 
Pract 1979;9:811. 

6 Kaplan GW. Circumcision; an overview. Curr Probl Pediatr 
1977;7:1. 



7 Fontaine P, Toffler WL. Dorsal penile nerve block for newborn 
circumcision. Am Fam Physician 1991;43;1327-33. 

8 Kirya C, Werthman MW Jr. Neonatal circumcision and penile 
dorsal root nerve block, a painless procedure. J. Pediatr 
1978;92:998. 

9 Rogers MC. Do the right thing: pain relief in infants and children. 
N Engl J Med 1992;326:55-6. 

10 Ryan CA, Finer NN. Changing attitudes and practices regarding 
local analgesiafornewbom circumcision. Pediatrics 1994;94:230- 
3. 

1 1 Blass EM, Hoffmeyer MA. Sucrose as an analgesic for newborn 
infants. Pediatrics 1991;87:215-8. 

12 Benine F, Johnston CC, Faucher D, Aranda JV. Topical anesthesia 
during circumcision in newborn infants. JAMA 1993;270;850-3. 



NCM J March/ April 1 996, Volume 57 Number 2 107 



PHYSICIANS' ROUNDTABLE 

Should Abortion Training Be a 
Requirement of Obstetrics and 
Gynecology Residencies? 



Deputy Editor's note: In 1 992 the percentage of obstetrics/gy necology training programs that included abortion training as 
a part of the residency curriculum had dropped from 22.6% (in 1985) to 12.4%. Present accreditation standards of the 
Residency Review Committee for Obstetrics and Gynecology do not require that residents learn how to perform abortions 
or how to provide contraception, only that residents learn "clinical skills in family planning." However, newly proposed 
standards would require that all programs provide residents with experience doing abortions. Programs that object to such 
training on religious, moral, or legal grounds would have to send residents to another institution for training in abortion. 

There are more than 270 accredited obstetrics/gynecology residency programs in the country, of which 45 are at Roman 
Catholic institutions and five at Roman Catholic medical schools. "Catholic hospitals are clearly opposed to abortion," states 
G. S. Showalter, vice president for member services for the Catholic Health Association. "We are not going to participate 
directly or indirectly in abortions." 

The Residency Review Committee for Obstetrics-Gynecology has always included a "conscience clause" that allows 
residents to forego learning certain procedures if they object to them. This "clause" is not acceptable to Catholic teaching 
hospitals. "We explained that [it] was unacceptable for a Catholic medical school to base the conscience clause only on 
individual conscience, because we have an institutional opposition," states C.J. Dougherty, director of the Center for Health 
Policy and Ethics at the Creighton University School of Medicine in Nebraska. 

My own thoughts on this issue, as well as those of three other North Carolina physicians, follow alphabetically. We 
encourage Journa/ readers to comment by sending letters to the Editor. — Edward C. Halperin, MD 



Commentary 

Watson A. Bowes, Jr., MD, Professor, Department of Obstetrics and Gynecology, 

University of Nortti Carolina at Chapel Hill ; ■ . ■ 

We need to set the record straight about what must be learned procedures. In other words, an ob-gyn service need not perform 

in a residency program in order to perform elective abortions, induced abortions to teach the procedures and treatments used 

Those techniques are: for an abortion. A resident need not actually perform induced 

1 . Transabdominal and transvaginal sonography to determine abortions in order to learn the techniques necessary to perform 

fetal age, fetal position, number of fetuses, position of them. 

placenta, and assess the completeness of a uterine evacua- Consequently, I believe that the performance of induced 

tion procedure. abortions should not be a prerequisite to accreditation of a 

2. Dilatation of the cervix with metal dilators, often preceded residency in obstetrics-gynecology. Furthermore, I believe that 
by the use of cervical inserts (laminaria, etc.). residents should be allowed to complete a residency without 

3. Exploration oftheuterinecavity with a sound and extraction having performed induced abortions. However, the resident 
of tissue from the uterus with a variety of forceps. should learn all the procedures and treatments enumerated 

4. Curettage of the endometrial cavity with suction and with above in the process of caring for women with spontaneous 
dull and sharp curettes. abortions or fetal deaths, and in performing fetal evaluations. 

5. The induction of uterine contractions with high-dose oxyto- Fourth-year medical students who want to learn how to 
cin or transvaginal prostaglandins. perform abortions should apply only to residency programs that 

6. Amniocentesis in a second-trimester pregnancy to remove offer such experience, either within the program itself or as an 
amniotic fluid or inject substances into the amniotic fluid, extramural elective. All residency programs should clearly 

All of these procedures or treaunents are used to treat state in their application brochures and promotional literature 

patients with incomplete spontaneous or missed abortions, or whether they offer training in induced abortion, 
second-trimester fetal deaths, or to perform fetal diagnostic Of the 274 US residency programs listed in the 1994 

1 08 NCMJ March/April 1996, Volume 57 Number 2 



APGO/CIB A Directory ofResidencies in Obstetrics and Gyne- 
cology, only eight (3%) required residents to perform first- 
trimester elective abortions, and four (1.5%) required residents 
to perform second-trimester abortions;' 89% of programs of- 
fered the opportunity to perform first-trimester elective abor- 
tions, and 82% the opportunity to perform second-trimester 
abortions. It does not seem to be the expressed opinion of the 
current directors of residency programs and chairs of ob-gyn 
departments that residents be required to perform abortions as 
part of their residency education. 

Finally, The Committee on Ethics of the American College 
of Obstetricians and Gynecologists issued the following state- 
ment at its meeting on April 12, 1994: "The Committee... has 
consistently recognized the importance of respect for the moral 
integrity of individual physicians. It is important to respect the 
moral integrity of institutions as well. The proposed Residency 
Review Committee requirement that all residency training 



programs provide the opportunity for training in elective abor- 
tion fails in this regard. This requirement would violate the 
moral integrity of some religious institutions that maintain 
residency programs. It should not be adopted. Other approaches 
should be explored for improving the training of physicians in 
abortion techniques." 

The effort to require that all accredited ob-gyn residency 
programs include training in induced abortion seems to arise 
from a perceived need to increase the number of abortion 
providers in the US.^"* As I have noted, the problem, if there is 
one, is not a lack of programs that offer training in elective 
abortion. Most ob-gyns, even those who are pro-choice, do not 
perform more than a few, and sometimes no, induced abortions. 
I dare say this is not because they do not know how, but rather 
because performing induced abortions is an unpleasant, emo- 
tionally draining task that runs counter to the obstetrician's 
usual work of enhancing and supporting fetal life. □ 



Commentary 

Takey Crist, MD, Crist Clinic for Women, Jacl(Sonville 

Pregnancy termination is a woman's problem. Those opposed 
to abortion are almost always men, usually religious fanatics 
who impose their anti-abortion beliefs on women who have 
become pregnant as a result of rape, incest, or failed contracep- 
tion. I want my colleagues to help me understand these men who 
hate women. Why are they threatened by women who want to 
have control over their reproductive organs? 

We can teach residents how to perform elective abortions, 
but until they are faced with a patient who requests one, they can 
never feel any empathy or experience the desperation and 
anxiety of these women. How can future physicians understand 
and learn the counseling and the emotional aspects associated 
with this specialized surgical procedure? Some women actually 
choose alternatives to abortion once they have been counseled 
by a properly trained physician. 

If Dr. Bowes' proposal is valid, I wonder why the principle 
didn't work when physicians started doing laparoscopic 
cholecystectomies. These physicians thought they knew the 
technique and instrumentation. Before they had any clinical 
experience, they started operating and their complication rate 
and surgical death rates skyrocketed. It wasn't until standards 
were adopted (the physician had to do at least 10 cases with 
another trained physician) that the complication rate decreased. 

During the past 25 years, I have watched the caliber of 
residents in obstetrics and gynecology deteriorate. Most of 
them are book-smart, knowledgeable, and can quote the litera- 
ture, but when faced with fire they can' t pour water out of a boot 
even with a neon sign that says "turn me over." Residents want 
to work from nine to five and would likely sit on their hands 
when encountering a breech presentation. 

As teachers, we have allowed students, interns, and resi- 
dents to dictate terms on what and how much they should or 



could learn. If the Residency Review Committee determines 
that performing elective abortions is part of the practice of 
obstetrics and gynecology, and if the American Board of 
Obstetrics and Gynecology will use competency in performing 
this procedure in the process of board certification, then ap- 
proved residency training programs must include abortion 
training or give residents access to clinical instruction in the 
procedure by some other means. 

Suppose birth control and family planning violate the 
medical student or house staffs moral code. Do we then excuse 
them from learning about lUDs, diaphragms, and other meth- 
ods of contraception? And what happens when future physi- 
cians refuse to learn about sexuality and deviant lifestyles and 
refuse to treat patients who are HIV positive? Hospital and 
training programs have outlined what is demanded and required 
for future physicians to learn, practice, and perform, and thus 
become board-certified to practice the specialty. If they do not 
want to undergo the required training, then they should find 
another profession. 

The abortion issue is fraught with emotion and politics. We 
need to stop playing games. The medical community — specifi- 
cally ob-gyns — has allowed the provision of abortion services 
to become marginalized. If 80% of ob-gyns in this country 
provided abortions as part of their normal practice, physicians 
such as David Gunn (who was killed outside an abortion clinic) 
would not have had to travel to five different cities a week to 
provide services. By eliminating abortion training and making 
it, at best, elective, and at worst, unavailable, the ob-gyn 
community devalues the service early in a residents's training. 
At the very beginning residents are given the message that 
abortions are less than "normal" or "necessary" surgical proce- 
diu^es. It follows that by the time ob-gyns are ready for private 



NCMJ March/April 1996, Volume 57 Number 2 1 09 



practice, they perceive the procedure as one that "someone else 
can do." Who, by all rights, should this be if not a gynecologist? 
Physicians who travel to many cities, like Dr. Gunn and others, 
take great personal risks. In fact, they are doing ob-gyns in these 
cities an immense favor. No longer do ob-gyns have to face 
botched abortions, patients in the emergency room, infections, 
or hemorrhage. These courageous physicians perform admira- 
bly, have a low complication rate, and cause few problems. 



Only when the ob-gyn community faces the problem 
honestly, and fully supports and encourages the training of 
gynecological residents, will we solve the problem of subject- 
ing those few doctors performing abortions to physical danger 
and making them targets of zealots and fanatics. It is up to our 
specialty to solve the problem. We owe it to our colleagues and 
our patients. □ 



Commentary 

Edward C. Halperin, MD, Deputy Editor, Professor and Vice Chair, Department of Radiation Oncology, 
Duke University f^edical Center, Durham 



The fundamental question is: What body of knowledge consti- 
tutes the practice of obstetrics and gynecology, and is the 
performance of elective abortions part of that practice? 

If the Residency Review Committee determines that per- 
forming elective abortions is part of the practice of ob-gyn, and 
if the American Board of Obstetrics and Gynecology will use 
competency in performing this procedure in the process of 
board certification, then approved residency training programs 
must include abortion training or give residents access, by some 
means, to instruction in the procedure. 

It seems that the ob-gyn community is not of one mind as 
to whether abortion training is an essential part of education in 
tlie specialty. Dr. Bowes' solution is "truth in advertising" and 
the free play of market forces. Residency programs should 
make their views on abortion, and the extent of training offered, 
quite clear; prospective house officers should shop for pro- 
grams with this information in hand. 

I find part of Dr. Bowes' analysis disingenuous. He says 
that residency training will instruct the house officer in all the 
procedural components needed to perform elective abortions 
because the components are used in related procedures. There- 
fore, even without performing abortions during the residency. 



residents will still have the necessary skills that, should the 
occasion arise, they will be able to do elective abortions because 
they know the constituent steps. I don't think much of this 
argument. Would you be enthusiastic about losing your appen- 
dix to a surgeon who knew how to make an incision, ligate blood 
vessels, suture (he skin closed, and a variety of other technical 
procedures, but had never actually done an appendectomy? The 
surgeon might be more suited to try than, for example, a 
diagnostic radiology resident without such technical training, 
but possessing individual technical skills without applying 
them is hardly a necessary or sufficient replacement for actually 
doing an appendectomy. I think that, on this point. Dr. Bowes 
skirts the crux of the issue. 

In many places in the US it is difficult for a woman to obtain 
a legal, medically supervised abortion. This is not, I think, 
principally because of the religious or moral views of the 
medical practitioners in the area. It is, instead, because physi- 
cians feel physically threatened or they are not trained in the 
procedure. This lack of access relegates women to criminal 
abortions. I suspect that some ob-gyn physicians, recognizing 
this lack of medical services, are trying to increase training in 
elective abortions. Q 



References 

1 Ling FW, Holzman GB, Mitchum MJ. APGO/CIBA Directory of 
Residencies in Obstetrics and Gynecology, 1994. Association of 
Professors of Gynecology and Obstetrics, 409 12th St., SW, Wash- 
ington, DC 20024. 

2 Grimes DA. Clinicians who provide abortions: the thinning ranks. 



Obstet Gynecol 1992;80:719-23. 

Westhoff C, Marks F, Rosenfield A. Residency training in contra- 
ception, sterilization, and abortion. Obstet Gynecol 1993;81:311-4. 
Rosenfield A. The difficult issue of second-trimester abortion. N 
Engl J Med 1994;331:324-5. 



Commentary 

Charles B. Hammond, MD, Professor and Chair, Department of Obstetrics and Gynecology, 
Duke University Medical Center, Durham 



Dr. Bowes' and Dr. Grist's well-articulated reviews reflect their 
opposite feelings about requiring experience in the elective 
termination of pregnancy during ob-gyn residency education. 
Both clearly are their own personal views, and I respect the 
sincerity of each. However, I think these two positions repre- 
sent, in many ways, the sad state that exists regarding elective 



abortion in the United States. I practiced for an interval before 
elective abortion was legalized, and I can document the trag- 
edies that occurred to women who had no other good options. 
Now, as I have performed legal abortions for patients in my 
practice, I find each to have been a difficult problem in its own 
right. My only mechanism for guidance has been what the 



110 



NCMJ Mcvch/April 1996, Volume 57 Number 2 



patient and I agree is best for her as an individual. I agree that 
abortion is a private matter, best handled between the patient 
and her physician. It is obvious that the answer to the abortion 
question lies somewhere between the two polar positions pre- 
sented. 

To complete the circle of argument about the pros and cons 
of legal abortion, it appears that part of the solution is lo prevent 
unwanted pregnancies. Thus, effective contraception and well- 
directed sex education should be mainstays of this prevention. 
But it is unlikely that all unwanted pregnancies will be pre- 
vented, and thus the problem of elective abortion remains. 
Despite all of the debate, I truly believe that legal abortion must 
remain an available (and safe) choice for American women. 

I direct an obstetrics-gynecology residency program and I 
will not force our residents to perform elective pregnancy 
terminations if that is their moral position. On the other hand, 
I clearly want all of our residents to be trained, competent, and 
experienced in managing the complications of spontaneous or 
induced abortion or of fetuses dead in utero. But for residents 
who are eager to learn how to perform elective abortion, I want 
to offer them the opportunity to practice the procedure. If done 
properly, elective abortion it is far more than a limited surgical 
procedure. 

Every obstetrics-gynecology resident needs to learn the 



techniques that Dr. Bowes lists, whether or not they plan to 
participate in die elective termination of pregnancy. They need 
these skills to provide adequate care for pregnant women. I also 
think that every resident should be offered the opportunity to 
perform, under supervision, elective termination if they so 
desire. I agree with Dr. Crist that many patients in the US do not 
have access to legalized termination of pregnancy because of 
realistic physician fear or too-limited training. However, I 
firmly disagree with him that the "caliber of residents in 
obstetrics and gynecology has deteriorated." They are bright 
and capable individuals who reflect what we, our Residency 
Review Committee, and our Board demand be in their curricu- 
lum and then, how well we teach it. 

As teachers of house staff, we struggle with the same 
concerns that all physicians and Americans have with this diffi- 
cult issue. So do our house staff I believe that the intermediate 
position taken by the American Board of Obstetrics and Gyne- 
cology and by the Residency Review Committee for Obstetrics 
and Gynecology to require appropriate training — but also to 
stop short of the requirementof actual performance — is reason- 
able and probably the only one available in this political 
climate. I hope that effective contraception can reduce the need, 
but those women who do need and request this service should 
continue to receive what I think is a fundamental right. □ 



/T 



^ 



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fine tune their writing skills during a special 
two-hourmedical writing workshop conducted 
by Journal Editor Dr. Francis A. Neelon from 
10 a.m. to noon, Sunday, March 17, at the 
Washington Duke Inn, Durham. 

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writing and ways to avoid them, effective 
transitions, rewriting and editing techniques, 
preparing manuscripts for submission, and 
the mechanics of publication. 

The workshop is free; space is limited. To 
register or for more information, please call 
Jeanne C. Yohn, Journa/managing editor, at 
919/286-6410, fax: 919/286-9219. 



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NCMJ March/April 1996. Volume 57 Number 2 111 



MEDICAL EDUCATION 



Resident Knowledge of Designations 
for iViedicaiiy Underserved Areas 

Deirdre C. Lynch, RhD, Theodore W. Whitley, PhD, Maria A. Clay, PhD, and Thomas G. Irons, MD 



Physician maldistribution, not physician supply, is a major 
barrier to the equitable delivery of health care in the United 
States.' This certainly is a concern in North Carolina. Strategies 
used to increase physician location in medically underserved 
communities include the awarding of scholarships or the for- 
giveness of loan repayment,^ the selection of medical students 
likely to practice in underserved areas, and educational activi- 
ties.' Educational efforts have included modification of cur- 
riculum content and location of clinical training sites in medi- 
cally underserved sites." 

Recent studies show that student gender, preference for 
specialty practice,' and attitudes toward the underprivileged' 
may predict who will serve in medically underserved areas, but 
there is conflicting information about whether educational 
programs alone can induce health care professionals to work in 
underserved areas.' Locating clinical training programs in 
medically underserved areas seems to produce more physicians 
who subsequently practice in underserved areas;" this may only 
reflect selection bias (participants choosing to study in 
underserved sites may already have an interest in working in 
underserved areas) rather than nurturing such interest. In any 
case, it is clear that we need to further examine whether 
educational approaches can stimulate vocational interest in 
underserved areas. 

As a first step we undertook to find out whether resident 
physicians knew the meaning of federal and state designations 
for medically underserved areas: HPSA (Health Professional 
Shortage Area) and MUA (Medically Underserved Area, from 
which an index of medical underservice is derived). These 
terms are used to identify areas that can receive financial and 



Drs. Lynch, Clay, and Irons are with the Generalisf Physician 
Program, and Dr. Whitley is Assistant Dean for Medical Educa- 
tion, East Carolina University School of Medicine, Greenville 
27858-4354. 



programmatic assistance.' Knowing the meaning of these des- 
ignations would be important to North Carolina physicians who 
plan to work in underserved areas, or to advocate assistance for 
these regions. 

We distributed surveys to 44 resident physicians with at 
least three years of training (and therefore likely to have made 
practice location decisions) about one month before the end of 
their third year of residency training at a site located in eastern 
North Carolina. Survey questions asked: 1) What words does 
the acronym MUA represent? 2) What words does the acronym 
HPSA represent? 3) List the three primary factors that influ- 
enced your choice of practice location. 

Thirty-five residents (80%) responded. Two correctly iden- 
tified the meaning of MUA, and two others identified the 
meaning of both HPSA and MUA. All four were enrolled in 
primary care residencies, and one had a payback service obliga- 
tion. Sixty percent of residents who attended medical school 
out-of-state planned to practice out-of-state, but only 13% of 
residents who attended an in-state medical school planned to 
practice out-of-state. This difference was not statistically sig- 
nificant. The most frequently stated reason for choice of prac- 
tice location pertained to geographical variables (mentioned on 
26 occasions) — climate, city size, terrain, and cultural ameni- 
ties. The second most common item affecting choice of practice 
location pertained to job characteristics (mentioned on 21 
occasions) — income, fiexibiUty, group practice, and colleagues. 
The third most common element related to familial factors 
(mentioned 14 times) — family ties and spouse employment 

We found that most residents with at least three years of 
training, at a site committed to meeting regional health care 
needs in eastern North Carolina, did not know the meaning of 
two common acronyms for medically underserved areas. This 
suggests the need for education about medically underserved 
designations, and perhaps equally importantly, about the incen- 
tives available for working in underserved areas. Of course, 
educational approaches alone will not resolve maldistribution. 
Physician distribution is influenced by other factors including 



112 



NCMJ March/April 1996, Volume 57 Number 2 



geographic variables, job characteristics, and familial vari- 
ables. Nevertheless, better education may be one of the least 
intrusive, and least expensive, ways to stimulate physician 
interest in medically underserved areas. □ 



Acknowledgments: This survey was supported in part by the 
Robert Wood Johnson Foundation. The authors thank the 
residency directors and support personnel who facilitated data 
collection, and the people who participated in this study. 



References 

1 Politzer RM, Harris DL, Gaston MH. Primary care physician supply 
and the medically underserved. JAMA 1991;266:104-9. 

2 Pathman DE, Konrad TR, Ricketts TC. The National Health Service 
Corps experience for young physicians in the late 1980s. JAMA 
1994;272:1341-8. 

3 RabinowitzHK. Recruitment, retention, and foUow-up of graduates 
of aprogram to increase thenumber of family physicians in rural and 
underserved areas. N Engl J Med 1993;328:934-9. 

4 Verby JE, Newell JP, Andresen SA, Swentko WM. Changing the 
medical school curriculum to improve patient access to primary 
care. JAMA 1991;266:110-3. 

5 Crandell JS, Volk RJ, Loemker V. Medical students' attitudes 



toward providing care for the underserved. JAMA 1993;269: 
2519-23. 

6 Li LB, Williams SD, Scammon DL. Practicing with the urban 
underserved: a qualitative analysis of motivations, incentives, and 
disincentives. Arch Fam Med 1995;4:124-33. 

7 Fowkes VK, Gamel NN, Wilson SR, Garcia RD. Effectiveness of 
educational strategies preparing physician assistants, nurse practi- 
tioners, and certified nurse-midwives for underserved areas. Pub 
Health Rep 1994;109:673-82. 

8 Taylor DA, Ricketts TC, KolLmaga JT, Howard HA. The Measure- 
ment of Underserv ice and Provider Shortage in the US. Chapel Hill, 
NC: NC Rural Health Research Program, 1994. 



Carolina Physician's Booicsiieif 



A Soul Lost Is Saved: A Memoir About Depression And Suicide 

Buckwalter JA, Dunlap J. Chapel Hill, NC: Professional Press, 1995, paperback, 129 pages, $12.50 

Reviewed by William B. BIythe, Marion Covington Professor of Medicine, Department of Medicine, 
Division of Nephrology, University of North Carolina, Chapel Hill, and Journal Associate Editor 



A Soul Lost Is Saved is an autobiographical account of a man's 
life-long struggle with, and ultimate victory over, clinical 
depression. What makes this book particularly interesting to 
readers of the North Carolina Medical Journal is that the 
author. Dr. Joseph Buckwalter, is Professor Emeritus of Sur- 
gery at the University of North Carolina at Chapel Hill and a 
resident of Chapel Hill. 

Dr. Buckwalter begins his account withadescriptionof his 
ancestry and his early years in Pennsylvania. He concludes his 
book with the realization that he has recovered from serious 
depression. This recovery has allowed him to look back on his 
life with insight and to look forward to his future with joyous 
anticipation. Sandwiched between the beginning and end of this 
129-page paperback is a brutally honest narrative of a life's 
highs and lows. Dr. Buckwalter is frank about his multiple 
suicide attempts. He also recounts the influence of family, 
friends, and physicians on his emotional peaks and valleys. 



Autobiographies of this genre often assume, without justi- 
fication, that the reader is exceptionally interested in the subject 
of the book. The fact of the matter is that the lives of most of us 
will be of little or no interest to the casual reader. Dr. Buckwalter 
is not guilty of this crime. His book is extremely well-written, 
at times gripping, always given to poignancy, and ends on a 
happy note. Such are the marks of good writing and reading. 

A Soul Lost Is Saved will appeal to all physicians, since 
depression is common among us; to patients afflicted by de- 
pression, as well as to those interested in a literate person's tale 
of his entanglement with the disease. □ 



Readers should direct correspondence and suggestions for 
books to review to Dr. Edward C. Halperin, MD, NCMJ Book 
Review Editor, Box 3085, Duke University Medical Center, 
Durham 27710. 



NCMJ March/ April 1996. Volume 57 Number 2 113 



In Memoriam 

The Journal Honors Two Long-Time Supporters: 
Dr Jay M. Arena and Ms. Jane K. Whalen 



Sad news sometimes seems to come in doublets. The Journal notes here of the loss of two of its long-time supporters, 
one whose name was widely known in North Carolina (and national) medical circles, and one who labored diligently in 
the background of the Journal's daily work. — Francis A. Neelon MD, Editor 



Jay Morris Arena, MD, came to North Carolina from his 
native West Virginia in 1930 to join the first class of 
students to receive the doctorate in medicine at Duke 
University in 1932. Except for internships at Strong Me- 
morial Hospital in Rochester, New York, and at the Johns 
Hopkins Hospital, in Baltimore, his entire career was spent 
in the Department of Pediatrics at Duke from which he 
retired as professor in 1979. He is justly renowned as the 
founder of North Carolina's poison control center and the 
inventor of the "child-proof cap for medication bottles. 
Ann Landers turned to him regularly for his advice on 
poisoning and the ingestion hazards of childhood. 

In 1979, Dr. Arena began a 16-year stint as a member 
of theyoMr/ia/'iEditorial Board. It was in thatcapacity that 
I first came to know him personally rather than as a snow- 
haired presence in the corridors of Duke Hospital. We 
often rode together from Durham to Board meetings in 
Raleigh. No stranger to service on the editorial boards of 
medical journals (he had served on eight before ours), he 
genuinely delighted in the direction and content of the 
Journal. Without doubt, if the present regulations limiting 
consecutive years of service had not taken effect, he would 
have continued on the Board beyond November 1995, 
when he stepped down. 

Butany further service would not last long before fate, 
it seems, would take a hand. Jay Arena died suddenly at his 
home on January 5, 1996. He was 86 years old, alert and 
vigorous to the end. The day before his death, he talked 
with me (to critique and support) my latest editorial in the 
Journal. He is survived by his wife, seven children, 1 1 
grandchildren, and a host of friends and colleagues who 
treasure the memory of a man who put service and commit- 
ment to medicine (and the Medical Society) at the fore- 
front. The Journal will miss his supporting presence. □ 



Jane Killoran Whalen was a less visible part of the 
Journal's activities, but on a day-to-day basis one of the 
most important. From September 1986, when she began 
service as former Editor Dr. Eugene Stead's editorial 
assistant until May 1994, when she (reluctantly) took a 
medical leave of absence, Jane Whalen was the linchpin of 
our daily activities. Hers was the voice that greeted callers 
to our office. It was she that typed the letters to our 
correspondents. She opened, catalogued, and kept track of 
manuscripts received, of the comments of reviewers, of Dr. 
Stead's daily schedule. 

In the days before our manuscripts were submitted on 
computer disks, Jane learned (not without trepidation and 
always with a certain allergic distaste) to enter those paj)ers 
into the computer en route to their eventual layout in the 
Journal. On one occasion, an untoward experience with an 
unrecognized keystroke command had obliterated all of 
her computer's memory, and that experience sensitized her 
forever to the unforgiving nature of computers. But she 
overcame her Luddite tendencies, to our immense benefit. 
The Journal appeared on lime, on schedule, and with 
minimal amounts of editorial dyspepsia largely because of 
her unflagging reliability. 

Even after that fateful May day two years ago when the 
least ominous of symptoms were translated by MRI scan 
into an unbendabic diagnosis, Jane continued to look 
forward to her "return" to the office. "Quit" was not a 
component of her lexicon. She accepted the indignities of 
aggressive therapy in hopes of a response that would 
restore independent function and allow her to resume work 
and activities with her six children and nine grandchildren. 
Unfortunately, what was required instead was brave accep- 
tance of an unwanted inevitability. She died on July 4, 
1995, released at last to a new kind of Independence. She 
leaves all of us enriched by her brave example and her 
efforts on our behalf. □ 



1 1 4 NCM J March/April 1996. Volume 57 Number 2 



MEDICAL JARGONESE 



The Gold Standard 



Eben Alexander, Jr., MD 



One doesn't have to read very much of the medical literature to 
encounter the term "gold standard" used in the sense of a really 
immutable standard against which similar things are to be 
compared. My attention was first called to this three years ago 
by a letter in the British MedicalJournal} The correspondent, 
an Irish chemist named P. Finbarr Duggan, had made a special 
study of the appearance of the term over the 1 years since 1 982. 
From 1987 through 1990 alone, Duggan found "gold standard" 
used in the titles of 35 papers and 373 abstracts (and he did not 
include papers in which the term appeared only in the text). 
"Gold standard" had been used in connection with such condi- 
tions as mental depression, leftventricular function, osteoporosis, 
and gastroesophageal reflux, to name a few. 

Recent literature has not avoided a dose of the gold stan- 
dard: In recent months Academic Medicine has used it for a 
paper about faculty development in a changing academic envi- 
ronment,^ Lancet for a 1995 letter to the editor discussing the 
quadruple theory for determining meta-analysis,' and theBm- 
ish MedicalJournal in "Minerva's Column" which stated that 
"Necropsy has the reputation of being the gold standard for 
diagnostic certainty — the mortuary is the temple of truth."* 

Even medical educators use the term. For example, the 
authors of a report from Mc Master University' stated that while 
they "...did not see the MCC [Medical Council of Canada] 
examination as the 'gold standard' of evaluation, it was none- 
theless an essential step to licensure." 

The entry under the gold standard in the 1956 Encyclope- 
dia Britannica' begins: "The gold standard is the monetary 



system in which the monetary unit is, or is kept at the value of, 
a fixed weight of gold." Further it states: 

"It seems probable. . .that some more or less distant ap- 
proximation to the original gold standard will for the 
foreseeable future be maintained in the United States and 
perhaps in many other countries. It should be said, how- 
ever, that no country with any intention of putting into 
effect unilaterally , as occasion seems to demand, a change 
in the gold value of its monetary unit can pretend, in any 
significant sense, to be a gold standard country." 
In volume 124 of the 1991 Encyclopedia Britannica^ one 
finds, under the entry on money, that the gold standard ended as 
a real international standard at the beginning of World War I. 
The world then Uved under what was called the "dollar" 
standard from the end of World War II lo 1971 , and today has 
a "modem monetary system" with a central bank in each 
country determining the value of that country's money. When 
one sees the value of the dollar expressed in yens, pounds, 
Deutsche marks, and other national forms of money, one can 
rightly conclude that the term, "gold standard," has lost its 
significance. In view of such a change, it is highly questionable 
whether scientific medicine should continue using the term 
"gold standard" to mean the best, or the value against which all 
others must be valued. I write this simply to raise that point and, 
as Duggan stated, "Because [biological testing being] in a state 
of perpetual evolution gold standards are, by definition, almost 
never reached."' □ 



References 

1 Duggan PF. Time to abolish "gold standard" (letter). BMJ 4 
1992;304:1568-9. 5 

2 Evans CH. Faculty development in a changing academic environ- 
ment. Acad Med 1995;70:14-20. 

3 dcBoer W, Ziekenhuis SA, Tytgat G. Letter to the editor. Lancet 6 
1995;345:1647-8. 7 



Minerva's column. BMJ 1995;310:542. 

Blake JM, Norman GR, Smith EKM. Report card from McMaster: 

student evaluation of a problem-based medical school. Lancet 

1995;345:899-902. 

Encyclopedia Brittanica 1956;498B. 

Encyclopedia Brittanica 1991 ;124: 333. 



Dr. Alexander is Professor Emeritus, Department of Neurosurgery, Bowman Gray School of Medicine, Medical Center Boulevard, 
Winston-Salem, and Journa/ Associate Editor. 



NCMJ March/April 1996, Volume 57 Number 2 



115 



CME Calendar 



March 14-17 

North Carolina Medical Society Spring Conference 

Place: Washington Duke Inn & Golf Club, Durham 
Info: Alan Skipper, NCMS, 800/722-1350 (in NC), 
or 919/833-3836 

March 15-16 

Neurology for the Primary Care Provider 

Place: Winston-Salem 
Credit" 1 1 hours Category 1 , AM A 

Info: Division of CME, Bowman Gray School of Medicine, 
910/716^450 or 800/277-7654 

March 16 

Innovations in Diabetes Management for Primary Care 

Place: Sarah W. Stcdman Center for 

Nutritional Studies, Durham 
Info: Duke Office of CME, 800/222-9984 or 

919/684-6485 

March 17 

Medical Writing Workshop 

Place: Washington Duke Inn & Golf Club, Durham 
Info: Jeanne C. Yohn, North Carolina Medical Journal, 

Box 3910 DUMC, Durham 27710, 919/286-6410, 

fax: 919/286-9219 

March 20-23 

20th Annual Internal Medicine Conference 

Place: Friday Center, UNC-Chapel Hill 

Credit: approx. 24 hours Category 1 , AMA 

Fee: $400 

Info: Registrar, UNC Office of CME, CB# 7000, 23 1 
MacNider Hall, UNC School of Medicine, Chapel 
Hill 27599-7000, 919/962-21 18, fax: 919/962-1664 

March 21 

Clinical Neuro-Ophthalmology Review 

Place: UNC-Chapel Hill 

Info: Christine C. Cotton, UNC Dept. of Ophthalmology, 

CB# 7040, 617 Burnett- Womack Bldg., Chapel Hill 

27599,919/966-5296 

March 22-23 

9th Annual Surgical Symposium and Harrill Lecture 

Place: Winston-Salem 

Credit: 9 hours Category 1 , AMA 



Info: Division of CME, Bowman Gray School of Medicine, 
910/716-4450 or Physician Access Line, 
800/277-7654 

March 25-28 

Alton D. Brashear Postgraduate 

Course in Head and Neck Anatomy 

Place: Medical College of Virginia, Richmond, VA 

Credit: 44 hours Category 1 , AMA 

Info: Dr. Hugo R. Seibel, Department of Anatomy, 

P.O. Box 980709, Medical College of Virginia, 

Richmond, VA 23298-0709 

April 1-2 

20th Annual Symposium of the 

UNC Lineberger Comprehensive Cancer Center: 

New Insights into the Genetic Basis of Cancer 

Place: Friday Center, UNC-Chapel Hill 
Info: Sara Rimmcr, 919/966-3036 

April 10-12 

Current Concepts of Clinical Infectious Disease 

Place: Boar's Head Inn, Charlottesville, VA 

Credit: 17 hours Category 1, AMA 

Fee: S455 (if before March 13) 

Info: Lynda E. Myers, University of Virginia, School of 
Medicine, Office of CME, Box 368, Health Sciences 
Center, Charlottesville, VA 22908, fax: 804/982-14 15 

April 13 

Hepatobiliary and Liver Transplant Update 

Place: Durham 

Credit: 8 hours Category 1, AMA 
Info: Duke Office of CME, 800/222-9984 or 
919/684-6485 

AprU 25-28 

16th Annual Medical Communications 

& Health Reporting Conference 

Place: The Crowne Plaza, Miami, FL 

Info: Jill Stewart, American Medical Association, 

515 N. State St., Chicago, IL 60610, 

fax: 312/464-5843 

April 26-27 
Practical Pediatrics 

Place: Winston-Salem 



116 



NCMJ M or chl April 1996, Volume 57 Number 2 



Credit 9 hours Category 1 , AMA 

Info: Division of CME, Bowman Gray School of Medicine, 

910/716-4450 or Physician Access Line, 

800/277-7654 

April 28-Mayl 

National Managed Health Care Congress 

Place: Washington, DC 

Info: NMHCC, 617/270-6000 

May 1-3 

4th Annual Healthlnfo Managed Health Care Information 

Technology Solutions Conference & Expo 

Place: Washington Convention Center, Washington, DC 
Info: NMHCC, 617/270-6000 

May 15-17 

Carolinas Medical Center Symposium 

Place: Charlotte Convention Center 

Credit: up to 24 hours Category 1 , AMA 

Fee: MD/PhD/DDS/DMD: $ 1 50 full conference, 

$100 single day; RN/RPh/AUied and Public Health: 

$75 full conference, $50 single day 
Info: Mary Anne Cox, CME Coordinator, CMHA Office of 

CME, 1366 E. Morehead St., Charlotte, NC 28204, 

704/355-8631 or 800/562-7314 

May 16-17 

The Legalities of Promoting & 

Advertising Pharmaceuticals 

Place: Washington, DC 

Info: NMHCC, 617/270-6000 

May 29-June 1 

20th Annual Update: Cardiology for the Primary Physician 

Place: Charleston, SC (during Spoleto Festival) 

Info: American College of Cardiology, 800/257-4739 

May 30-31 (and October 31 -November 1) 
ACLS Provider Course 

Place: Rex Healthcare, 4420 Lake Boone Trail, Raleigh 

Credit: 13.75 hours, AAFP 

Fee: $150 

Info: Iris Ahlheit, RN, Course Coordinator, Rex Healthcare, 

4420 Lake Boone Trail, Raleigh 27607, 

919/783-3161 

May 31 

American Medical Writers Association Workshops: 
Ethics of Authorship and Editorship, Punctuation for Clar- 
ity and Style, Grant Writing: NIH and Non-NIH Resource 
Options and Strategies, Building a New Drug Application 
Place: The Friday Center, UNC-Chapel Hill 
Fees: AMWA members: $70/session, $130 for 2; 

non-AMWA members: $80/session, S150 for 2; 



registration deadline: April 19 
Info: Cindy Toso, Glaxo Wellcome, Inc., Five Moore Drive, 
Research Triangle Park 27709, 919/483-3981 

May31-June 1 

Current Therapy in Venous Disease 

Place: The Carolina Inn, Chapel Hill 

Credit; approx. 10 hours Category 1, AMA 

Fee: $175 

Info: Registrar, UNC Office of CME, CB# 7000, 23 1 

MacNider Hall, UNC School of Medicine, Chapel 
HiU 27599-7000, 919/962-21 18, fax: 919/962-1664 

June 5-9 

Comprehensive Internal Medicine Board Review Course 

Place: Winston-Salem 

Credit- 32 hours Category 1, AMA 

Info: Division of CME, Bowman Gray School of Medicine, 

910/716-4450 or Physician Access Line, 

800/277-7654 

June 11-15 

5th Annual Advanced Coronary 

Interventions Symposium 

Place: Westin Resort, Hilton Head, SC 

Credit: 18 hours Category 1, AMA 

Fee: $695 

Info: Mary Anne Cox, CME Coordinator, CMHA Office of 

CME, 1366 E. Morehead Sl, Charlotte, NC 28204, 

704/355-8631 or 800/562-7314 

June 21 

UNC Ophthalmology Residents' Day 

Place: UNC-Chapel Hill 

Info: Christine C. Cotton, UNC Dept. of Ophthalmology, 

CB# 7040, 617 Burnett- Womack Bldg., Chapel HUl 

27599,919/966-5296 

July 29-August 2 

25th Annual Emery Miller Medical Symposium 

Place: Myrtle Beach, SC 

Credit: 20 hours Category 1 , AMA 

Info: Division of CME, Bowman Gray School of Medicine, 

910/7164450 or Physician Access Line, 

800/277-7654 

September 16-19 

Disease Management Congress 

Place: Washington, DC 

Info: NMHCC, 617/270-6000 



[ CME guidelines: Send info to: NCMJ CME, Box 3910 
l DUMC, Durham, NC 2771 0, or fax to: 91 9/286-921 9. 



NCMJ March/April 1996, Volume 57 Number 2 117 



r 



The North Carolina Medical Journal 

Recommended Reading for All Physicians 
and Health Care Professionals 




Method of Payment: 



The Journal is the only publication about North 
Carolina medicine written by North Carolina physi- 
cians. Each issue features a diverse mix of topical and 
thought-provoking socioeconomic and scientific ar- 
ticles pertinent to medical practice in North Carolina, 
plus a special pull-out section for patients. 

Subscription to the Journal is a benefit of mem- 
bership in the North Carolina Medical Society. Indi- 
vidual subscriptions can also be ordered. Treat a 
friend or colleague to a one-year gift subscription (six 
issues) by simply filling out the coupon below. 



Please start my one-year subscription^* 



My Name 
$20 enclosed, payable to the 

North Carolina Medical Society (NC Address _ 

residents add 6% sales tax = $21.20) 



I I Charge to: VISA — 

M/C 

Name on Card: 

Account #: 



Expiration Date: 



City/Slate/Zip 



Please send a one-year gift subscription to*: 

Name 



I I New I I Renewal 



Address 



Send to: North Carolina Medical Society, City/State/Zip 

Attn: Journal subscription, P.O. Box 27167, 

Raleigh, NC 27611-7167 *Please allow 4-6 weeks for delivery of the fu-st issue. 



^ 



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1 1 8 NCMJ March/April 1996, Volume 57 Number 2 



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RURAL FELLOWSHIP IN PRIMARY CARE 

North Carolina - The Mountain Area Health Education 
Center's (MAHEC) Rural Fellowship invites 
applications for a 4th year residency training 
experience in Rural medicine. Applicants must be 
Primary Care Physicians who have graduated from 
an accredited residency program in Family Practice, 
general Internal Medicine or Pediatrics. A formal 
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medicine in rural areas. Because the practice of 
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For further information please contact Harry H. 
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Administrative Coordinator, Regional Outreach 
Programs, Mountain Area Family Health Center, 1 18 
W.T. Weaver Boulevard., Asheville, NC 28804; 
704-258-0670. 



NCMJ March/April 1996, Volume 57 Number 2 119 



Aphorisms 
of the Month 

Daniel J. Sexton, MD, Editor 

"General Advice: Part II" 



When a friend is in trouble, don't annoy him by asking 
if there is anything you can do. Think up something 
appropriate and do it. — E.W. Howe 

When a man tells you what people are saying about 
you, tell him what people are saying about him; that 
will immediately take his mind off your troubles. 

— E. W. Howe 

If you ever have to support a flagging conversation, 
introduce the topic of eating. — Leigh Hunt 

Do not bite at the bait of pleasure till you know there is 
no hook. — Thomas Jefferson 

In the right between you and the world, back the world. 

— Franz Kafka 

Borrow trouble for yourself, if that is your nature, but 
don't lend it to your neighbors. — Rudyard Kipling 

Decide promptly, but never give your reasons. Your 
decisions may be right, but your reasons are sure to be 
wrong. — Lord Mansfield 

Do not overestimate the decency of the human race. 

^L. Mencken 



Never invest in anything that eats or needs repairing. 

—Billy Rose 

When you play, play hard; when you work, don't play 
at all. — Theodore Roosevelt 

Never try to reason the prejudice out of a man. It 
wasn't reasoned into him, and cannot be reasoned out. 

— Sydney Smith 



Fax aphorisms to Dr. Sexton at 919/684-8358 



Index to Advertisers 


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MedCost, Inc. 


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Medical Billing Practice, Inc. 


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Mountain Area Family Health Center 


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NC Primary Care Network, Inc. 


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Triad Radiographic Imaging 


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T. Rowe Price Investment Services, Inc. 


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120 



NCMJ March/April 1996, Volume 57 Number 2 



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Alzheimer's Disease: Why is There a Disparity in Prevalence? 

Double Primary Neoplasms among Patients with Genitourinary Malignancy 

Family Practice and Pediatric Professionals' Responses to Domestic Violence 

Improved Hearing Results from Stapedotomy with Myringotomy 

Medical Education and Health Care Reform: from Osier to AHEC 

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NORTH CAROLINA 
MEDICAL JOURNAL 

For Doctors and their Patients 



EDITOR 

Francis A. Neelon, MD 

DEPUTY EDITOR 
Edward C. Halpeiin. MD 

CONSULTING EDITOR 

Eugene A. Stead, Jr., MD 

ASSOCIATE EDITORS 

Eben Alexander, Jr., MD 

Winslon-Salem 
Wmiam B. Blylhe, MD 

Chapel urn 
F. Maxlon Mauney, Jr., MD 

Asheville 
James P. Weaver, MD 

Durham 

MANAGING EDITOR 

Jeanne C. Yohn 

phone: 919/2S 6- 6410 

fax: 919/286-9219 

e-mail: yohnCXX)l@mc. duke.edu 

BUSINESS MANAGER 

Donald R. Wall 



SECTION EDITORS 

Eugene W. Linfors, MD 
Daniel J. Sexton, MD 

EDITORIAL BOARD 
CHAIR 

Margaret N Marker, MD 
Morxshead City 

MEMBERS 
Jack Hughes, MD 

Durham 
Patrick D. Kenan, MD 

Durham 
Assad Meymandi, MD 

Raleigh 
William G. Porter, MD 

Charlotte 
Mary J. Raab, MD 

Greenville 
C. Stewart Rogers, MD 

Greensboro 
J. Dale Simmons, MD 

Raleigh 
Thomas G, Slovall, MD 

Winston-Salem 



May/June 1996, Volume 57, Number 3 

Published bimonthly as the official organ of the 

North Carolina Medical Society (ISSN 0029-2559), 

222 N. Person St., P.O. Box 27167, Raleigh, NC 27611-7167 

The Society is not to be considered as endorsing the views and opinions advanced by authors of 

papers delivered at the Annual Meeting or published in the official publication of the Society. — 
Constitution and Bylaws of the North Carolina Medical Society. Chap. IV. Section 3. pg. 4. 



NORTH CAROLINA MEDICAL JOURNAL 

Editorial ofTice: Box 3910, Duke University Medical Center, Durham, NC 27710, (phone: 
919/286-6410, fax: 919/286-9219, e-mail: yohn0001@mc.duke.edu), is owned and published 
by the North Carolina Medical Society under the direction of its Editorial Board. Copyright© 
1996 North Carolina Medical Society. Address manuscripts and connmunicaLions regarding 
editorial matters, subscription rates, etc., to the Managing Editor at the Durham address listed 
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2200 W. Main St.. Suite B-210. Room 12, Durham, NC 27705.) Listed in lnJ£x Medicus. All 
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endorsement of the subject or claims of the advertisement. 

Advertising representative: 

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NCMJ May/June 1996, Volume 57 Number 3 



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orth Carolina Medical Journal 

FOR DOCTORS AND THEIR PATIENTS 

May/June 1996, Volume 57, Numbers 

Cover: A port-wine stain on the left cheek and lip of a 26-year-old woman Oeft) has faded significantly after three trealmenU with the 
flashlamp-pulsed tunable dye laser (right). Photos courtesy of Duke Division of Dcrmatologic Surgery. See article on page 1 80. 

DIMENSIONS OF DOCTORING 

132 Pediatricians Beware! The Need for Early Recognition and Action in Spousal Abuse 

Robert F. Perry, MD, James V. PianelH, JD, LLM, Heidi Long, MS II, and Jana S. Davis, NS IV 

136 Detecting Domestic Violence: A Pilot Study of Family Practitioners 

Stephanie A . Molliconi, MPH, and Carol W. Runyan, MPH, PhD 

A PIECE OF A NORTH CAROLINA DOCTOR'S MIND 

140 A Body To Die For Gregory J. Davis, MD 

THE TEACHING AND LEARNING OF MEDICINE 

142 Medical Education and Health Care Reform: From Osier to AHEC 

William O. McMillan, Jr., MD, FACP, with commentary by W. Randolph Chitwood, Jr., MD - 
148 A New Paradigm for Continuing Medical Education: 

Implications for North Carolina in an Age of Change in Health Care Delivery 

James C. Leist, EdD, William E. Easterling, MD, Susan Gustke, MD, and Thomas E. Sibert, MD, 

with commentary by Margaret N. Marker, MD 

THE SPECTRUM OF DISEASE 

158 Alzheimer's Disease Then and Now: Can We Really Explain the Disparity in Prevalence? 

John M. Lewis, MD, with commentary by Albert Heyman, MD, and Florence Nash, MA 

TOXIC ENCOUNTERS 

162 "Macbeth Does Murder Sleep": The Mysterious Mythic Melatonin Morass Ronald B. Mack, MD 

CLINICAL PRACTICE 

172 Biologic Hazards of Double Primary Neoplasms among Patients with Genitourinary Malignancy 

J. Brantley Thrasher, MD. Richard K. Dodge, MS, Judith E. Robertson, CTR, and David F. Paulson, MD 
176 Improved Hearing Results from Stapedotomy with Myringotomy 

Chapman T. McQueen, MD, Jason R. Burke, BA, Tracey G. Wellendorf, MD, 

Vincent N. Carrasco, MD, and Harold C. Pillsbury, III, MD, FACS 
180 Treatment of Benign Cutaneous Vascular Proliferations with the 585-nm Flashlamp-Pulsed Tunable Dye Laser 

Aleksandar Krunic, MD, PhD, Carlos Garcia, MD, Greg Viehman, MD, and Robert E. Clark, MD, PhD 



HEALTH WATCH 

153 Organ and Human Tissue Donations: Recycling Life J. Dale Simmons, MD, MPH 



BULLETIN BOARD 

126 Letters to the Editor 170 Instructions for Authors 

146 Climerick: "The MICU" by Victor F.Tapson, MD 184 New Members 

150 "Combaton the Tenth Floor of a Veteran's Clinic" 187 Classified Advertisements 

by Edward V. Spudis, MD \ 88 Aphorisms of the Month 

168 CME Calendar 188 Index to Advertisers 

124 NCM] May/June 1996, Volume 57 Number 3 




It's a good feeling having 
someone in my court." 

"Getting squeezed from both ends isn't 
pleasant. Losing sleep over professional 
liabilities isn't why 1 studied to be a medical 
professional. When questions 
of accountability arise, it 
seems everyone has their 
representative except 
the doctors. 

Medical Mutual has 
always been there. 
Even when the 
others pulled out. That 
means a lot. First, and foremost. 
It means that I can concentrate 
on my patients needs instead 
of worrying about liability 
insurance. Medical Mutual is 
in my court. Always has 
been. That's a good feeling." 



Medical Mutual 



Medical Mutual Insurance Company 
of North Carolina 

4505 Falls of the Neuse Road 

PO Box 98028 

Raleigh, NC 27624-8028 

Tel: (919)872-7117 

(800)662-7917 

Fax: (919) 878-7550 



Letters to the Editor 



^ 



Missing Our Monthly Issues 
To the Editor: 

I am sorry that young writers in North Carolina will not 
enjoy as many opportunities for communication now that the 
Journal is publishing fewer issues per year. I'm sure it makes 
Dr. Neelon's task more difficult and I do not envy him. 

I certainly have enjoyed sharing my craziness with inter- 
ested Journal readers these past 15 years. 

Ronald B. Mack, MD 

Associate Professor, Department of Pediatrics 

Bowman Gray School of Medicine 

Medical Center Boulevard 

Winston-Salem, NC 27157 

From the Editor: 

Dr. Mack's latest installment of "Toxic Encounters" ap- 
pears on page 162. 

March/April Issue Worth Keeping 
To the Editor: 

The March/ April7oMrna/ was superb — on target and timely. 
It becomes part of a working library rather than being relegated 
to the recycle bin. 

Elizabeth P. Kanof, MD 

Raleigh Dermatology Associates, PA 

800 Springfield Commons Drive, Suite 115 

Raleigh, NC 27609 

To the Editor: 

I want to congratulate Dr. Neelon, Dr. Halperin, and the 
Journal's Editorial Board for a fantastic March/April issue. 
When it arrived in my mail, I glanced at some of the titles, 
hoping that I would not find anything of interest so that I could 
dispose of it quickly , as I do so many other medical journals. But 
then I saw articles of genuine interest on almost all domains. In 
looking at these articles, I expected that the tides would be 
deceiving and that the articles themselves, uninteresting. Once 
again, I was wrong. 

Almost against my better judgment, I read most of the 
articles in the issue. More importantly, I used the information 
with my peers and with students. Dr. Neelon's article on his 
experience visiting English general practitioners was excellent 
(NC Med J 1996;57:92-7), as was Bob Seligson's update on 
managed care in North Carolina (NC Med J 1996;57:70-3). The 
"Health Watch" article on age-appropriate interventions for 



preventing child injury (NC Med J 1996;57:87-90) was one of 
the best I have ever seen, and I am incorporating it into our clinic 
practice. 

Keep up the good work. 

Adam O. Goldstein, MD 

Clinical Assistant Professor 

UNC Department of Family Medicine 

Manning Drive, CB# 7595 

Chapel Hill, NC 27599-7595 



Managed Care: The Ultimate Model 
To the Editor: 

1 write in response to the "Anatomy of Managed Care" 
featured in the March/April Journal (NC Med J 1996;57:70- 
86). 1 serve as manager of the ultimate model of a managed care 
system: a correctional institution. 

In my position as medical directorof the Jail Health Service 
in the Robeson County Detention Center, I see a defined 
population, from the lower socioeconomic levels, with aconsti- 
tutional right to totally government-supported medical care. 
Health benefits include hospitalization, mental health services, 
full dental care, and full prescription services. There are no 
deductibles or co-payment provisions. The system operates 
here, in North Carolina, virtually unrecognized by the public. 

Our services have been defined, not by legislation, but by 
the courts. In 1976 the federal Supreme Court decided that 
deliberate indifference to serious illness or injury constituted 
cruel and unusual punishment, was prohibited by the Eighth 
Amendment, and was actionable. Since then, an avalanche of 
class action suits have defined and expanded "serious illness or 
injury" to encompass the benefits we now provide. 

In carrying out my duties, my first consideration is to 
minimize Uability risk. The prison population is highly liti- 
gious. One-third of all federal lawsuits are brought by inmates; 
three-quarters of them allege violation of civil rights, such as 
providing inadequate health care. I have to remember that 
prisoners are all "con men" looking for a way to get rich, and 
that they are familiar with our court system. Even when they 
don' t win, the cost of defending against lawsuits is significant. 

My second consideration is cost because every dollar used 
by me comes from tax revenue, and I am a taxpayer. If someone 
presents with a potentially expensive illness, as a prudent care 
manager the first thing I try to do is get them out of the system. 
Failing this, I try to get them treated as cheaply as possible. 



126 



NCMJ May/June 1996, Volume 57 Number 3 



Third in my priority ranking, I try to provide professionally 
reasonable medical care. 

Does the system work? 1 don't know, but we do provide 
care to inmates for about half what the county spends for even 
less-inclusive benefits for its employees. It you would like to 
see a model of the finished product currently being built in our 
society, look at us. 

H. Strawcutter, MD 

Medical Director, Jail Health Service 

Robeson County Detention Center, 122 Legend Road 

Lumberton, NC 28358 

Balancing the Scales of Practice Expense 
To the Editor: 

The comments of Dr. Andrew R. Price about Medicare 
reimbursement are, on face value, correct (Letter to the Editor: 
"Reimbursement Clarification," NC Med J 1996;57:65-6). 
Primary care physicians and sub-specialists are reimbursed on 
the same scale for performing the same procedures. 

However, inequities within the reimbursement fee sched- 
ule do exist. For example, because practice expenses have been 
based on inaccurate historical charges, a neurosurgical proce- 
dure is reimbursed at a higher rate than an office visit. This 
practice is currently being studied by HCFA, as dictated by 
Congress. When appropriate practice expense values are ap- 
plied, it is likely that reimbursement will go down for proce- 
dures and up for office visits. Changes based on this study will 
go into effect January 1, 1998. 

When office visits are reimbursed at higher, more accurate 
rates, I suspect that more medical students will be attracted to 
the primary care specialties. This is especially true for rural and 
other areas where the Medicare population represents a signifi- 
cant portion of a physician's patient load. 

Gary O. Bean, MD, Immediate Past President 

NC Academy of Family Physicians, Inc. 

P.O.Box 18469 

Raleigh, NC 27619 

Children's Defense Fund's Yearbook Available 
To the Editor: 

The Children's Defense Fund's annual State of America's 
Children Yearbook 1996 is now available. This analysis of the 
status of US children chronicles recent developments and data 
in the areas of family income, child health, child care and early 
childhood development, children and families in crisis, adoles- 
cent pregnancy prevention and youth development, education, 
and youth violence. 

Journal readers may find it useful in their work. The 
Yearbook can be ordered from CDF Publications, 202/662- 
3652. 

Belva Finlay, Senior Editor 

Children's defense Fund 

25 E St., NW 

Washington, DC 20001 



Diagnosing British Health Care 
To the Editor: 

Dr. Neelon's article in the March/April Journal, "Behind 
the Surgery Doors: A Look at What English General Practitio- 
ners Do," (NC Med J 1996;57:92-7) is direct, to the point, and 
a pleasure to read. 

I was especially interested since Dr. Neelon's experience 
so closely paralleled my own in England at nearly the same 
time, when I visited as the Wyeth Scholar from the North 
Carolina AHEC system. I spent most of my time with consult- 
ants and Dr. Neelon visited general practitioners, but our 
impressions of the satisfaction of the English public with their 
system were the same. 

Like Dr. Neelon, I have attempted to share my observations 
on the state of the National Health Service (NHS), especially the 
four recent changes that have caused immense concern among 
England's health care professionals and medical educators 
("Changes in Britain's Health Care: An American Attempts to 
Revisit 'From the London Post,'" JAMA 19%;275:789-793). 
The general practitioner's new role as "fundholder" is the most 
important of the four because it places the GP in an intrinsically 
contradictory position — trying to simultaneously provide opti- 
mal care for patients, while minimizing the expenditures for 
their care. 

As Dr. Neelon emphasized, the pracUces of the NHS can 
stimulate us to examine assumptions, such as the idea that every 
patient must have a physical examination at each encounter. If 
we decide to change our own health care systems, we should 
remember that NHS practices are not in steady state equilib- 
rium; they continue to be the object of convulsive politico- 
economic revisions. 

J. Gary Maxwell, MD 
Professor, UNC Department of Surgery 

Program Director, Surgery Residency Training Program 

New Hanover Regional Medical Center, P.O. Box 9025 

Wilmington, NC 28402-9025 

Scrutinizing Sclerotherapy 
To the Editor: 

The article by Drs. Hren, Garcia, and Clark, "Sclero- 
therapy of Telangiectases Using Sodium Tetradecyl Sulfate 
(Sotradecol)" (NC Med J 1996;57:42-6), was interesting and 
informative. I have treated a lot of telangiectases and varicose 
veins over the years, and agree that sotradecol is the sclerosant 
of choice. When diluted to a concentration of 0.3% or less, there 
is very little pain on injection, even when minor extravasation 
occurs. Hypertonic saline, on the other hand, is often quite 
painful. 

I have found that I avoid ulcers if I stop injecting as soon 
as any extravasation is noted and if the solution injected is 
dilute. Quite a bit of sclerosant solution can be injected directly 
into larger vessels without fear of extravasation using a blunt 
injector through a small venotomy if vein ligation is performed. 
In my practice, coupling sclerotherapy and ligation of second- 



NCMJ May/June 1996, Volume 57 Number 3 1 27 



ary varicosities helps a number of people with larger varicosi- 
ties. 

In my experience, residual pigmentation relates more to the 
size of the treated vessel than to the amount or concentration of 
solution used, probably because more erythrocytes are 
extravasated from larger vessels. The pigmentation can be 
decreased somewhat by using gauze bolsters to induce mild 
compression over treated larger veins. This also reduces the 
amount of thrombosis and phlebitis that follows treatment of 
larger vessels. 

Finally, using a table that can be tilted slightly to bring the 
head up and the feet down can facilitate injection of small veins 
and telangiectases. 

William E. Bowman, Jr., MD 

Greensboro Surgical Associates, PA 

Wendover Medical Center 

Suite 411, 301 E. Wendover Ave. 

Greensboro, NC 27401 

Dr. Garcia responds: 

I agree with Dr. Bowman that solradecol is an excellent 
sclerosant and has few complications when used correctly. The 
most common problem is hyperpigmentation (occurring in 
30% of patients). Pigmentation occurs in vessels <0.3 mm in 
diameter when high concentrations of sclerosant are used, and 
in vessels >0.4 mm even with low concentrations. In general, I 
do not believe that compression is necessary. 

Larger vessels usually disappear with thrombosis and 
pigmentation, but I have noticed enormous variability from one 
person to the next when treating vessels of exactly the same 
size. Such variability cannot be accounted for by increasing 
vessel size or increasing sclerosant concentration. Identical 
treatment of identical-appearing veins in carefully matched 
patients can produce a baffling variety of clinical outcomes and 
paradoxical results. Second-generation vessels (those that ap- 
pear after treatment) are more resistant to sclerotherapy. 
Neovascularization or "matting" is common after multiple 
treatments; occasionally, after only one. I give one to three 
treatments initially then wait three to six months before resum- 
ing treatment. 

Ulceration is extremely rare if the injection is stopped as 
soon as extravasation is noted. Other factors responsible for 
skin necrosis include high concentration of sclerosants, high- 
injection pressures, and anatomic location (face, ankles). An 
infrequent but intriguing phenomenon is the appearance of 
extensive tissue necrosis approximately five days after seem- 
ingly uneventful treatment. 

A recent theory holds that telangiectases can be treated 
better by injecting adjacent reticular ("feeder") veins. The idea 
is that telangiectases are "caused" by venous hypertension, and 
treatment should be directed by "plugging" the leaking high- 
pressure outflow. Other cited advantages include the need for 
fewer treatments, ease of cannulation and lower likelihood of 
rupture in larger vessels, and the minimization of extravasated 



erythrocytes and sclerosant. I have found this technique is 

useful for very specific subsets of reticular "feeder" veins 

between 2.5 mm-3.0 mm connected to telangiectases >0.6 mm, 

but no belter across the board for other kinds of telangiectases. 

Carlos Garcia, MD, Fellow Associate 

Dermatologic Surgery and Cutaneous Oncology Unit 

Box 3915, Duke University Medical Center 

Durham, NC 27710 

Getting Patients to Stop Smoking 
To the Editor: 

Because tobacco use remains the number one preventable 
cause of death and disease in the US and in North Carolina, 
physicians must continually counsel all patients who smoke to 
quit. Unfortunately, people smoke for many reasons. Smokers 
come in all ages, both genders, and smoke seemingly unlimited 
numbers of brands. To help clinicians give the best advice to 
their patients, we offer the tips we use with our own patients: 

1. "Visualize yourself as a non-smoker." 

2. "Tell me your exact quit date." 

3. "What made you start smoking again after previously 
quitting? How can we avoid this problem now?" 

4. "Let's think of a hobby that can occupy your hands and 
mind." 

5. "How much money is it worth to you to quit smoking?" 

6. "If you have a cigarette within 30 minutes of wakening, 
you are probably addicted to cigarettes." 

7. "Drink eight glasses of water a day while quilting smok- 
ing." 

8. "Since you do not want to quit smoking right now, what 
will it lake to get you to want to quit smoking?" 

9. "If you keep smoking, you may need to have a facelift by 
the age of 40." 

10. "Smoking low-tar cigarettes is like buying a loaf of poison 
bread, eating just a little bit at a time." 
We encourage Journal readers to contribute their own 
additional tips on how to counsel patients to quit smoking. 

Georjean Stoodt, MD, Chair, Jennifer Fortney, MD, 

Clare Sanchez, MD, Dick Rosen, MD, 

Adam Goldstein, MD, Brian Forrest, Gregg Stave, MD 

North Carolina Medical Society Subcommittee on Tobacco 

222 N. Person St., P.O. Box 27167 

Raleigh, NC 27611 

Stemming the Tide of 
Work-Related Illness and Injury 
To the Editor: 

Physicians in North Carolina can and should help prevent 
and treat job-related illnesses and injuries in industry. I write to 
share my own experience, and to solicit residents and senior 
physicians to consider changing their practice style. 

I am a senior orthopedic surgeon based in Wilmington. For 
eight years I have worked at a poultry-processing firm in Mount 
Olive. I find the one-day-a-week service challenging and grati- 



128 



NCMJ May I June 1996. Volume 57 Number 3 



fying. Over the past seven years, I have successfully treated 
many workers at the plant, which employs more than 2,000 
people. No patient has needed surgery, and many patients have 
returned to work despite diagnoses of carpal tunnel syndrome 
or low back problems. 

My job begins at pre-employment, when I conduct a 
careful exam to look for potential problems in a "new hire" 
(screening by a trained nursing staff enhances the efficiency of 
this process). I consider disabilities from previous work, re- 
sidual trauma from sports or motor vehicle accidents, and 
interruptions of work or military service due to disease, and 
carefully study medical records of prior surgeries or medical 
conditions, which job applicants are asked to provide. If physi- 
cal examination of the musculoskeletal system is abnormal or 
questionable, especially as relates to prior surgery, I order x- 
rays before rendering a decision about the applicant's health 
status. The requirements of the applicant's job at the plant are 
carefully weighed against any current deficits or complaints. 

The occupational physician's role docs not end with ex- 
amination, but also requires a knowledge of the workplace. I 
conduct site inspections and assess ergonomic factors related to 
workers' weight, height, muscle strength, and environmental 
and other job stresses they may encounter on the job. These are 
important elements. In North Carolina, non-back related claims 
or injuries rose by more than 2000% from 1983 to 1991 . OSHA 
issued its first citation based on ergonomic hazards in 1989 and 



several related cases are pending. 

Ergonomics, the study of how people work, helps health 
care professionals decrease workplace hazards related to cumu- 
lative trauma disorders (strained back, carpal tunnel syndrome, 
tendinitis, trigger finger, de Quervain's disease, and ill-defined 
musculoskeletal dysfunction). North Carolina is a leader in the 
nation's ergonomics movement and has established the Ergo- 
nomic Resource Center at NC State University in Raleigh. The 
Center, which opened June 2, 1995, has set aside S50,000 for 
grants to investigate industrial production and its effects on 
workers. Physicians may apply for funds to study ways to 
decrease the numberof lost work days at specific sites (for more 
information contact: Sponsored Research Program, NC Ergo- 
nomics Resource Center, 703 Tucker St., Raleigh, NC 27603, 
919/515-2052, fax: 919/515-8156). 

The American Academy of Orthopaedic Surgeons encour- 
ages senior and semi-retired physicians to seek contracts in 
industry. We hope to stem the tide of cumulative trauma 
disorders before they reach the point of surgical treatment and 
the accompanying temporary or permanent lost time by work- 
ers. 

James R. Dineen, MD 

Clinical Professor, UNC Orthopaedic Surgery 

Board Member, Ergonomics Resource Center, NC State 

Coastal Orthopaedics, PA 

1616 Medical Center Drive 

Wilmington, NC 28401 



Training to Perform Abortions 

Doctors' Comments Fuel the Controversy 

From the Editor: 

In the March/April Journal, four physicians discussed whether ob/gyn residents should be required to learn abortion 
procedures ("Physicians' Roundtable," NC Med J 1996;57:108-1 1). The controversial nature of the subject prompted 
additional commentary, which follows. Text may have been abridged due to space limitations. 



To the Editor: 

In May 1960, on our second daughter's birthday, I 
began my rotating internship on the OB service at Cook 
County Hospital. Working long hours, I assisted at many 
deliveries, mostly performed with pudendal block anesthe- 
sia. I cared for many women after the fact of (self-) induced 
abortion, some with endometritis. 

I went on to a career in surgery marked not by brilliance, 
but by diligence and compassion. My career has been a 
source of great satisfaction to me and has, I hope, been a 
source of comfort and aid to my patients and an example to 
residents and students. I cannot imagine having been any- 
V thing other than a physician. However, if in that summer of 



1960 I had been told to perform an abortion or "choose 
another profession," I would have had to choose another. 

I know of no compelling secular arguments against 
abortion (or against assisted suicide), but as a Catholic 
physician, I do believe that life is a gift from God. I may 
support that life and give it comfort, but I may not choose to 
end it. 

William G. Sullivan, MD, FACS, Associate Director 

Trauma Service and Wake AHEC Surgery 

Clinical Professor of Surgery 

UNC-Chapel Hill 

3024 New Bern Ave., Suite 304 

Raleigh, NC 27610-1255 



NCMJ May I June J 996, Volume 57 Number 3 1 29 



To the Editor: 

Although abortion is legal, the issue still divides our 
nation. It is no wonder that it also divides the obstetrics and 
gynecology community. I am a woman and I am opposed to 
abortion. I don't hate women, nor do I feel threatened by 
those who want to have control over their reproductive 
organs. I applaud them, for I think abstinence is a realistic 
solution. I have put this into practice in my life as a 36-year- 
old waiting for marriage. 

I do not think that abortion or pregnancy termination is 
"only" a woman's problem. Abortion profoundly affects the 
woman involved, but has ramifications for the father and 
extended families as well. And without doubt, abortion 
dramatically affects the life terminated before fruition, per- 
haps the life most easily overlooked. A few years ago 
Newsweek published an article lamenting the generation lost 
to AIDS, a generation denied their full contribution to the 
world because they were struck down in their prime. I ask, 
who mourns the several generations denied any years of life 
at all? Loss of those lives affects our whole community. 

I want to speak to women who have felt that abortion 
was the only rational solution. Our society and the medical 
profession, wittingly or unwittingly, haveabettcdyourchoice. 
We have fostered the belief that life is worth living only if it 
has certain "qualities" and "advantages," and that when 
those are missing, it is humane to prevent further "suffering" 
by ending life. The medical community has played a huge 
part in the deception that a "fetus" isn't a unique life but 
merely part of a woman's reproductive organs. And — the 
most pernicious deception of all — the idea that once the 
surgical procedure of abortion is over the problem is solved. 
This has not been true for the many women who have 
confided in me. I apologize for the real suffering these 
deceptions have caused. But there is a cure available from 
the greatest physician that ever lived: forgiveness. 

I have deep misgivings about a profession dedicated to 
the preservation of life that would offer training for the sole 
purpose of ending a life. I would hate to see physicians who 
wanted to practice ob/gyn because of their love for women 
and babies turned away by a subset of their profession on a 
crusade for abortion. The pro-choice cause wants abortion to 
remain a choice; I say, please allow physicians who believe 
abortion is morally wrong the choice of serving as obstetri- 
cians and gynecologists. 

Nancy L. Jones, PhD, Assistant Professor 

Department of Pathology 

Bowman Gray School of Medicine 

Medical Center Boulevard 

Winston-Salem, NC 27157-1072 

To the Editor: 

As an obstetrician/gynecologist, I disagree with Dr. 
Halperin'sargumentthat"losing your appendix toasurgeon 



who [knows] how to make an incision, ligate blood vessels, 
suture the skin... but had never actually done an appendec- 
tomy," is inferior to having the operation performed by a 
surgeon who has actually done the procedure. The compo- 
nents of the operation outlined by Dr. Bowes are not merely 
representations of elective abortion procedures, they are the 
procedure. The absence of a beating heart is of no signifi- 
cance to the technical aspects of abortion training. The 
appropriate analogy for Dr. Halperin is whether a surgeon 
who has never taken out an appendix containing a fecalith 
should take out one that does contain a fecalith. 

I congratulate Dr. Bowes again for his stand on abortion 
and for the expertise that he brings to the discussion of this 
issue. 

Steve Nickisch, MD 

50 Doctors Drive 

N-1 Doctors Building 

Asheville, NC 28801 

To the Editor: 

The four commentaries on abortion training for resi- 
dents clearly demonstrate a spectrum of emotions: from the 
thoughtful and reflective comments of Dr. Bowes (pro-life) 
and Dr. Hammond (pro-choice), to the misinformed com- 
ments of Dr. Halperin and the pejorative comments of Dr. 
Crist. 

Dr. Halperin may find Dr. Bowes' analysis "disingenu- 
ous," and may not "think much of [his] argument," but as a 
gynecologist, I find Dr. Bowes' assessment of the situation 
indeed pertinent. Dr. Halperin practices in another discipline 
so I am sure he does not understand Dr. Bowes' allusion to 
the fact that the surgical care of a patient with an incomplete 
spontaneous or missed abortion or second-trimester fetal 
death requires the same knowledge and skills as do either 
first- or second-trimester therapeutic (elective) abortions. 
The only difference is that in one case the baby is dead and 
in the other the baby is alive, at least prior to the procedure. 

The question of whether we need to train more physi- 
cians is worth pondering. Let's look at the math. Presently, 
there are 19,041 ob/gyn residents in training. If 89% of the 
programs offer the opportunity to perform first-trimester 
elective abortions and 3% require residents to perform first- 
trimester abortions, then more than 17,000 residents know 
how to perform first-trimester abortions. And, since 82% of 
residency programs provide the opportunity to perform (and 
1.5% require the performance of) second-trimester abor- 
tions, there is a potential pool of 16,000 residents to do 
second-trimester abortions. 

According to the Alan Guttmacher Institute, in 1992 
there were 2,582 abortion providers in the United States, and 
252 residency programs (92% of 274) that performed abor- 
tions. I find it hard to believe the comments repeated by Dr. 
Halperin that it is "difficult for a woman to obtain a legally 



130 



NCMJ May/ June 1996, Volume 57 Number 3 



medically supervised abortion" in the US and that abortions 
are not available because physicians "feel physically threat- 
ened or they are not trained in the procedure." Clearly, the 
arguments fail under the weight of evidence. My question is: 
How many more physicians need to be trained? Surely, 
enough is enough. 

I have been involved in resident training for more than 
15 years. I concur with Dr. Hammond that our present 
residents are "bright and capable individuals." Contrary to 
Dr. Crist, these young men and women work extremely hard, 
but in my experience, even residents who are pro-choice and 
willingly do abortions during their training end up doing 
very few as their careers progress. Perhaps, as C.S. Lewis 



has suggested, we have an innate sense that distinguishes 
right from wrong, especially when it comes to the issue of 
taking life. 

I agree that residents must learn the techniques , have the 
decision-making capabilities, and be able to carry out the 
procedures that Dr. Bowes outlined. But I reject the notion 
that the taking of a developing human life could or should be 
mandated, simply to advance a social agenda. 

James B. Hall, MD 

Director, Gynecologic Oncology 

Carolinas Medical Center 

P.O. Box 32861 

Charlotte, NC 28232-2861 



Guidelines for Letters: 

Letters must be typed and double-spaced. Letters are subject to editing and abridgment and should be no longer than 500 
words. We will consider longer letters as editorials for possible publication elsewhere in the Journal. For longer letters, send 
a 3 1 /2-inch computer diskette with the text written in MS DOS- or Macintosh-compatible format. We customarily send letters 
that address specific points in articles to the original authors for response. Send letters to: North Carolina MedicalJournal, 
Box 3910, Duke University Medical Center, Durham, NC 27710, fax: 919/286-9219, e-mail: yohn0001@mc.duke.edu 



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NCMJ May/ June 1996, Volume 57 Number 3 1 31 



DIMENSIONS OF DOCTORING 

Pediatricians Beware! 

The Need for Early Recognition and Action in Spousal Abuse 

Robert F. Perry, MD, James V. Pianelli, JD, LLM, Heidi Long, MS II, and Jana S. Davis, NS IV 



The recent trial of O.J. Simpson heightened our awareness of 
the crime of spousal abuse. It is a commentary on our society 
that this unfortunate expression of sociopalhic behavior rarely 
comes to public light except in its most sensational form, and 
then only when discussion seems to serve the motives and 
interests of the media. In actuality, spousal abuse is a pervasive 
phenomenon that has been ignored, tolerated, and even ac- 
cepted by most cultures throughout the course of history.' 

Our ostensibly sophisticated criminal justice system often 
fails to consider non-fatal assault and/or battery by a male upon 
his spouse as a crime, treating it instead as a mere domestic 
squabble — a private quarrel between family members — pre- 
cipitated by, even expected from, the daily stresses of 
cohabitation, and better left to resolution by the combatants.^ 

Only recently has the medical profession recognized that 
spousal abuse is a major public health problem, areal pathologic 
entity with defined etiologic and prognostic features.' But 
medicine has yet to adopt a consistent, unified protocol to 
prevent spousal abuse from occurring or to begin its therapy. 
Sadly, the diagnosis is usually made retrospectively, after the 
infliction of serious injury or(all too frequently) at postmortem 
examination." 

Spousal abuse exists in many forms. It is surprisingly 
far-reaching in incidence and extent, and affects all socioeco- 
nomic groups.' Gil Garcetti, District Attorney for Los Angeles 
County, has stated that the murder of a spouse (the predictable 
endpoint of escalating domestic violence) occurs every five to 
six days in his jurisdiction. Epidemiologists have identified a 
number of variables that may cause or contribute to spousal 
abuse: young age, cohabitation without marriage, divorce, 
depression, pregnancy and the postpartum period, and sub- 
stance abuse.* Still, no definitive pattern of demographic, 
sociologic. or health-related factors can categorically identify 



which women are likely to be victimized or predict accurately 
which women are at imminent risk for abuse. 



When Abuse Coexists 

During the past decade, the research-based policy statements of 
the American Academy of Pediatrics have prodded the spe- 
cialty of pediatrics toward an aggressive, pro-active position on 
the diagnosis and reporting of suspected child abuse cases.' 
Pediatricians now routinely consider the battered child syn- 
drome and its variants in the differential diagnosis of many 
clinical presentations.' In essence, attention to this problem has 
sharpened clinicians' suspicions about crimes against chil- 
dren.' Because of widespread public support for the position of 
pediatrics, many states have enacted laws to protect children 
and to punish offenders.'" Health care professionals are now 
"mandated reporters," empowered and required to convey any 
suspicion of child abuse, neglect, or other maltreatment to the 
appropriate law enforcement or child protective agency." This 
has led to a dramatic increase in both interventional programs 
and criminal prosecutions.'^ 

Surprisingly, the specialty of pediatrics has not shown a 
similar degree of interest in the seemingly related condition of 
spousal (mother) abuse, despite McKay's report that child 
abuse and spousal abuse typically coexist within families and 
that practitioners often miss the association." Campbell sup- 
ported the coincidence of wife abuse and child abuse and 
suggested that physicians can more effectively protect battered 
children by recognizing when the mother also needs protec- 
tion.'" 

Oftentimes, the general pediatrician is the physician with 
whom a mother has most contact. Given the trust that parents 



Dr. Perry is Medical Director, The Pee Dee Clinic, 1 630 Military Cutoff Road, Wilmington 28403. Ms. Davis is coordinating a research 
project at the Clinic on recognizing spousal abuse in the pediatric clinic setting. She is a fourth-yearnursing student at the University 
of North Carolina at Wilmington. Mr. Pianelli is an attorney specializing in medical issues and a partner at McGehee and Pianelli, 
Houston, TX. Ms. Long is a second-year medical student at East Carolina University School of Medicine, Greenville. 



132 



NCMJ May/June 1996. Volume 57 Number 3 



place in Iheir j)ediatrician's judgment and advice, and the 
personal bond based on that trust, the pediatrician is often 
viewed as a confidant by the child's mother. Either directly or 
vicariously, as primary physician to the child, a formal 
doctor-patient relationship is established between mother and 
pediatrician. ''The pediatrician is often the first, and sometimes 
the only, medical professional with whom an abused woman 
has contact. This notion is supported by Elliot and Johnson who 
reported that none of 42 abused women routinely saw a physi- 
cian (for example, for general health maintenance)." It is 
therefore appropriate that pediatricians develop an objective 
system to help them recognize the often subtle signs and 
symptoms of spousal abuse and to facilitate immediate medical 
and legal intervention, protection for both mother and children, 
and long-term management of the condition. 

The very first paragraph of Nelson's Textbook of Pediat- 
rics, a reference known to all physicians, says: "Pediatrics is 
concerned with the health of infants, children and youths, their 
growth and development and their opportunity to achieve full 
potential as adults.. .[the] pediatrician must be concerned with 
social or environmental influences, which have a major impact 
on the health and well-being of children and their families. . . ."" 
Children cannot maximize their potential for development in a 
setting of family violence, no 
matter who is the specific vie- ^^^^^~~~^~~~ 
tim of that violence. In many "SpouSOl ObUSG iS 
cases abuse is non-selective, 

directed at both mother and '' '^ On impOrTanT 
child.'* In other cases, the pediotricians and 

husband's hostility is directed 

only at his wife, and he func- 
tions as an otherwise loving father to his children. This latter 
expression of domestic violence does not, however, spare the 
child from harm. On the contrary! Burman and Allcn-Meares 
report that children who witness extreme domestic violence 
often exhibit debilitating symptoms analogous to a post-trau- 
matic stress disorder." Furthermore, Thormaehlen and 
Bass-Field point out that children who grow up in violent 
households tend to become the next generation of victims (or 
perpetrators) of violence.^" The medical literature amply docu- 
ments the long-term deleterious effects of family violence on 
children.^' In most cases of domestic violence, the child is 
wimess to the assault and its aftermath — and that alone repre- 
sents a form of emotional/psychological abuse. By actively 
searching for signs or symptoms of spousal abuse in the mother, 
and thereafter implementing some meaningful intervention, the 
pediatrician fulfills the role of advocate for and protector to the 
child set forth in Nelson's prime directive. 



Pediatricians' Perspective 

We suggest that pediatricians, like ob-gyns and other primary 
care providers, are in a special position. They have an opportu- 
nity to develop a broad-based protocol that will screen for 



possible spousal abuse and, when suspected or identified, 
implement a well-defined system for documenting, formally 
reporting, and assisting in the interventional management of the 
abused spouse. We believe that pediatricians are in a special 
position because violence against women is most common 
during the child-bearing years, particularly pregnancy and the 
postpartum period. Gielcn et al interviewed 275 women on 
three occasions during pregnancy and at six months postpar- 
tum; 19% had experienced moderate to severe violence prena- 
tally , and 25% in the postpartum period." Parker et al, in a study 
of 1,203 women, reported that abuse during pregnancy was 
common and possibly a risk factor for low birth weight." 

The pediatrician is in a position to actively change commu- 
nity attitudes about domestic violence. To their credit, the 
specialties of internal medicine and family practice have taken 
a stand on this issue and developed a number of clinical models 
to address these concerns.^ Dubowitz and King recently pro- 
posed a structured general format for the screening of family 
violence in the pediatric setting." Unfortunately, no uniform 
protocol as yet has been incorporated into the mainstream of 
general medical practice. 

In devising such a protocol, we must attempt to identify the 
elements of the history, the physical appearance, and the 

emotional expressions of the 
mother that should raise the 
doctor's index of suspicion 
about possible spousal abuse. 
Obviously, evidence of frank 
physical trauma makes the de- 

termination of abuse urgent 

and necessitates direct ques- 
tioning about the source of the injury. More often than not the 
presentation is subtle, but once the physician's suspicion is 
raised, he or she must look for a history of present or past 
instances of domestic violence. 

Stewart found that many abused women, particularly those 
who were pregnant or postpartum, met the diagnostic criteria 
for a major depression.^' Hence, the initial office evaluation for 
suspected spousal abuse should include a general assessment of 
the mother's affect, mood, etc. Possibly the specialty of pediat- 
rics has placed so little emphasis on this issue because most 
victimized women do not exhibit overt evidence of abuse, and 
may even attempt to conceal their injuries from others in order 
to entirely deny the family discord. Thus, the stigmata of 
violence may not be readily apparent to the doctor," and it may 
therefore be helpful to use a comprehensive, non-threatening, 
interview to discern the minor symptoms and the occult mani- 
festations of abuse. 

Given that the field of pediatrics is moving toward a 
family-oriented approach to health care, two of us (RFP, JSD) 
have begun to study the value of asking specific questions about 
the likelihood of an abusive home environment. These ques- 
tions (Table 1, next page) are incorporated into the parent 
interview at well child visits. We also have developed a list of 
historical and physical findings in the child that suggest the 



real and endemic, 
health issue facing 
other practitioners." 



NCM J May/June 1 996, Volume 5 7 Number 3 133 



Table 1. Interview questions that may reveal spousal abuse 

♦ What adults live in the home? 

♦ What is the relationship of the child to each adult? 

♦ Is there anything upsetting going on at the home? 

♦ How are you (mother) feeling? Is everything okay? 

♦ Are you able to cope with most of the pressures at home? 

♦ Are there any pressures that you cannot handle? 

♦ Is there any discord between the adults in the home? 

♦ Is that discord affecting the child? 

♦ Do you think that the child feels intimidated or threatened by 
anyone in the home? 

♦ Do you ever feel physically or emotionally threatened by anyone 
in the home? 



possibility of family violence and which should prompt the 
physician to investigate further (Table 2, above). Already we 
have observed that, prompted by such questioning, some abused 
mothers will confide in the pediatric professional. 

Obviously, what we are proposing is no simple task. 
Obviously, too, it will require multidisciplinary input. Spousal 
abuse is real and endemic. It is an important health issue facing 
pediatricians and other practitioners. We must make the recog- 
nition and the diagnosis of family socio-pathology a priority 
because in protecting the mother from non-accidental injury we 



Table 2. Historical and physicial findingsthat 


indicate the possibility of family violence 




behavior problems 




bed wetting 




chronic headaches 




multiple or frequent somatic complaints 




abnormal sleep patterns/nightmares 




aggressive behavior 




speech delay/abnormality 




delayed social development 




school problems — cognitive or behavioral 




failure to thrive 




excessive fear of adults 



best serve the interests of the child. At the same time we can 
ensure, to the best of our abilities as physicians, that all children 
in our care ultimately reach their full potential. □ 

Editor's note: The National Domestic Violence Hotline has 
established a toll-free. 24-hour hotline, 800/799-SAFE (7233). 
TDD 800/787-3224. Physicians are urged to share the number 
with patients they suspect are being abused and offer them a 
confidential and private setting to make a call when they come 
in for medical visits. 



References 

1 Ileise L. Violence against women: the hidden health burden. World 
Heal Slats Q 1993;46:78-85. 

2 Bash KL, Jones F. Domestic violence in America. NC Med J 
1994;55:400-3. 

3 McAfee RE. Physicians and domestic violence: can we make a 
difference? JAMA 1995;273:1790-1. 

4 Mercy JA, Saltzman LE. Fatal violence among spouses in the United 
States 1976-1985. Am J Pub Health 1989;79:595-9. 

5 Smith PH, Gittelman DK. Psychological consequences of battering: 
implications for women's health and medical practice. NC Med J 
1994;55:434-9. 

6 Saunders DG.HambergerLK.HoveyM. Indicators of woman abuse 
based on a chart review at a family practice center. Arch Fam Med 
1993;2:537-43. 

7 American Academy of Pediatrics, Provisional Committee on Child 
Abuse. Guidelines for the assessment of child sexual abuse cases. 
Pediatrics 1991;87:254-60. 

8 Newberger EH. Pediatric interview assessment of child abuse chal- 
lenges and opportunities. Ped Clinics North Am 1990;37:943-54. 

9 McCall DE. Crimes against children: a guide to child protection for 
parents and professionals. Fuquay-Varina, NC: Research Triangle 
Publishing, 1995. 

10 The Texas Family Code, Sect. 261.002. Sampson ATindall's Texas 
Family Law Annotated, 1995. 

11 The Texas Family Code, Sect. 261.101. Sampson (feTindall's Texas 
Family Law Annotated, 1995. 

12 Runyan K. impact of legal intervention on sexually abused children. 
J Peds 1988;113:647-53. 

13 McKay MM. The link between domestic violence and child abuse: 
assessment and treatment considerations. Child Welfare 
1994;73:29-39. 

14 Campbell JC. Child abuse and wifeabuse: the connections. Maryland 



Med J 1994;43:349-50. 

15 Texas medical malpractice: the physician-palientrelationship. Hous- 

ton Law Rev Vol. 22, Sect. 1.01. 

16 Elliott BA, Johnson MM. Domestic violence in a primary care 
setting: patterns and prevalence. Arch Fam Med 1995;4:113-9. 

17 Behrman RE. Nelson Textbook of Pediatrics, 14th cd. Philadelphia: 
W.B.Saunders, 1992, pi. 

18 Yegidis BL. Family violence: contemporary research findings and 
practice issues. Comm Mental Health J 1992;28:519-30. 

19 Burman S, AUen-Meares P. Neglected victims of murder: children's 
witness to parental homicide. Social Work 1994;39:28-34. 

20 Thormaehlen DJ, Bass-Field ER. Children: the secondary victims of 
domestic violence. Maryland Med J 1994;43:355-9. 

21 Richters JE, Martinez P. The NIMH community violence project: I. 
Children as victims of and witnesses to violence. Psychiatry 
1993;56;7-21. 

22 Gielen AC, O'Campo PJ, Faden RR, et al. Interpersonal conflict and 
physical violence during the childbearing years. Soc Sci Med 
1994;39:781-7. 

23 Parker B, McFarlane J, Soeken K. Abuse during pregnancy: effects 
on maternal complications and birth weight in adult and teenage 
women. Ob Gyn 1994;84:323-8. 

24 Saunders DG, Kindy P. Predictors of physicians' responses to 
woman abuse: the role of gender, background, and brief training. J 
Gen Int Med 1993;8:606-9. 

25 Dubowitz H, King H. Family violence: a child-centered, 
family-focused approach. Ped Clinics North Am 1995;42:153-66. 

26 Stewart DE. Incidence of postpartum abuse in women with a history 
of abuse during pregnancy. Canadian Med Assn J 1 994; 1 5 1 : 1 601 -4. 

27 Koss MP, Heslet L. Somatic consequences of violence against 
women. Arch Fam Med 1992;1:53-9. 



134 



NCMJ May I June 1996. Volume 57 Number 3 



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DIMENSIONS OF DOCTORING 

Detecting Domestic Violence 

A Pilot Study of Family Practitioners 

Stephanie A. Molliconi. MPH, and Carol W. Runyan, MPH, PhD 



Nearly a quarter of women patients seen by family practitioners 
are physically assaulted by iheir partners each year.' ■^ Evidence 
is mixed as to how helpful medical providers are to abused 
women.'''* Direct questioning by physicians can help identify 
abused women,'* because patients do not often initiate a discus- 
sion of their abuse, instead believing that doctors should broach 
the subject.' Abused women do say they respond truthfully to 
questions about abuse.' 

Despite the effectiveness of direct questioning, Friedman 
and coworkers found that only 30% of primary care physicians 
believed that questions about abuse should be asked routinely, 
and only 40% said that they ever made inquiries about abuse at 
annual visits.' In a family practice setting, less than 7% of 
female patients were asked about relationship problems, only 
2% were asked about verbal abuse, and even fewer than that 
about physical abuse.' 

Few studies have tried to understand why physicians so 
rarely ask patients about abuse or to specify the barriers to 
detection of abused patients. Gremillion and Evins reviewed 
these in the September 1994 issue of this Journal!' Possible 
barriers include: failure of abused women to self-identify; lack 
of provider training in the identification of abused women; lack 
of provider time; providers' fear of offending patients; a sense 
of powerlessness to "fix" the situation; and lack of referral 
resources.'""'^ 



Ms. Molliconi works for HealthPartners, Center for Health Pro- 
motion, Minneapolis, MN. Dr. Runyan is with the University of 
North Carolina Injury Prevention Research Center and UNC's 
Department of Health Behavior and Health Education, CB# 
7505, Chapel Hill 27599-7505. This research was funded by a 
grant from the National Center for Injury Prevention and Control 
to the UNC Injury Prevention Research Center (#R01- 
CCR402444). 



To investigate these issues, we asked 144 physicians 
attending a statewide family practice conference to complete an 
anonymous, 75-item, self-administered questionnaire (Table!, 
next page). Questionnaires were distributed in person and 
collected in a marked box at the two-day conference. Some 
questionnaire items were adapted from earlier research,'^ and 
all were pilot-tested on three university-based family physi- 
cians and revised based on feedback about question clarity. We 
asked respondents to consider the possibility that female pa- 
tients age 18 and older might be experiencing actual or threat- 
ened physical assault, sexual assault, or rape by a boyfriend or 
former boyfriend, husband, or former husband. Respondents 
were explicitly told to exclude from consideration any incidents 
in which the victim was under age 18 or in which the assailant 
was a parent, sibling, other non-spouse relative, or a stranger. 



Results 

Sample description. Fifty-nine of 144 surveys (41%) were 
returned. One respondent was a physician ' s assistant and one a 
nurse practitioner; the remaining 57 were family physicians. 
Ninety-two percent of the respondents were currently in prac- 
tice, 72% in private settings. Ninety-three percent were white 
and 71 % male. The sample included more females (29%) than 
the proportion of physicians in North Carolina (19%)." 

Three-quarters of the respondents indicated some expo- 
sure to abuse as a medical issue (through journal articles, 
lectures, or workshops), but 25% had had no formal exposure 
to the topic. Interestingly, 46% of the respondents reported 
personal experiences with abused women in their families or 
among close friends or colleagues. 

Providers' behavior: asking about abuse. Although 76% of 
providers indicated that they believed identification of abuse is 
an appropriate activity for health care providers, on average 
respondents indicated that they ask fewer than one in three of 
their female patients about relationships and fewer than one in 



136 



NCMJ May/ June J 996. Volume 57 Number 3 



13 about the possibility of abuse. Even though few ask, most 
providers believe that abuse is rare in their practices; 73% 
estimated that less than 10% of their female patients had 
experienced any abuse during the past year. Providers who had 
previous exposure to information on abused women believed 
that abuse was more common (they estimated, on average, that 
14% of patients had experienced abuse during the past year) 
than did providers with no such exposure (whose mean estimate 
was 7%). 

Those with prior exposure to information on abuse had 
asked more of their patients about the possibility of abuse than 
had those with no exposure (9% vs 3%), but the groups did not 
differ in the likelihood of asking patients about the nature and 
safety of personal relationships (28% vs 27%). Respondents 
who had asked about relationships as part of routine patient 
histories said that they did so during discussion of sexual 



protection or "gynecological-related issues." 

In contrast, no doctors regularly asked patients about the 
]30ssibility of abuse. A number of providers indicated that they 
asked about that possibility only when they found strong 
evidence that abuse had occurred (for example, obvious cuts or 
bruises, or actual patient reports of battering). Others said they 
asked about abuse when the patient had a known history of 
abuse or "marital discord." One provider commented that he 
asked about abuse if the woman was known to be the "daughter, 
wife, or girlfriend of an alcoholic or angry man." 

Barriers to asking about abuse. We asked providers to evaluate 
the extent to which specific factors affected their inquiries 
about abuse using a six-point scale that ranged from 1 ("Does 
not keep me from asking") to 6 ("To a great extent keeps me 
from asking") (Table 1, below). A factor was considered a 



Table 1. Sample questions from domestic violence survey given to family practitioners 



During the past year, what percent of female patients in your 
practice do you think may have experienced at least one 
incidentoi actual or threatened physical or sexual assault by 
their male partners? % experiencing one incident 

During the past year, what percent of adult female patients 
have you asked specifically if they have ever been threat- 
ened or assaulted by a male partner? 

% you've asked about abuse 



Health care providers disagree on the amount of attention 
they should devote to Identifying abused female patients. In 
your opinion, how appropriate is it for health care providers 
to try to identify female patients who have been abused? 
(circle only one number ) 



not at all appropriate 
1 2 3 



very appropriate 
5 6 



At times, health care providers choose not to ask patients about the possibility of actual or threatened violence In relationships. 
When you do not ask patients about abuse, to what extent do the following keep you from asking? (circle only one number 
for each question) 



Keeps you from asking about abuse 

concern about offending my patients 

not wanting to interfere in my patients' private lives 

inadequate time to inquire about abuse during office visits 

my discomfort in asking or hearing about possible abuse 

not knowing where to refer patients who say they have been abused 

my belief that asking about abuse won't change anything 

don't think to ask 

my belief that nothing I can do as a health care provider can 

make a difference in ending the abuse 
inadequate time to follow up with the patient if abuse is identified 
feeling that the problem of abuse is too complicated to deal with 
husband or boyfriend came with patient, but is not in the 

examination room with patient 
husband or boyfriend is in the examination room with the patient 
my belief that each woman is responsible for getting 

herself out of an abusive relationship 



Does not keep 
om asking 
2 



me fi 



To a great extent keeps 
me from asking 



2 
2 
2 
2 
2 
2 

2 

2 
2 

2 
2 



3 
3 
3 
3 
3 
3 
3 

3 
3 
3 

3 
3 



4 
4 
4 
4 
4 
4 
4 

4 
4 
4 

4 
4 



5 
5 
5 
5 
5 
5 
5 

5 
5 
5 

5 
5 



6 
6 
6 
6 
6 
6 
6 

6 
6 
6 

6 
6 



NCMJ May /June 1996. Volume 57 Number 3 



137 



barrier lo asking about abuse if the respondent indicated a score 
in the range of 4 to 6. Overall, the most commonly identified 
barrier lo asking about abuse was that the provider personally 
knew the patient (cited by 30% of respondents) or her partner 
(cited by 33%). 

Providers with some prior information about abuse were 
less likely than those without such information to indicate that 
the following were significant barriers: fear of offending pa- 
tients (17% vs 36%), fear of interfering in patients' private Hves 
(12% vs 21%), feeling uncomfortable discussing abuse (7% vs 
37%), and feeling that abuse is too complicated to deal with 
(17% vs 36%). Interestingly, prior exposure to abuse informa- 
tion did not change the likelihood that physicians thought to ask 
about abuse or their beliefs that women were responsible for 
ending the abuse. 

More female than male respondents indicated that inad- 
equate time during clinic visits was a barrier to asking patients 
about abuse. Eighty-two percent of females and 56% of males 
indicated that they didn't think to ask about abuse. Females 
were less likely than their male counterparts to indicate that the 
following were significant barriers: interfering in patients' 
private lives (6% vs 18%), discomfort in asking (0% vs 18%), 
believing that abuse is too complicated to deal with (12% vs 
24%) and believing that the woman is responsible for ending the 
abuse (0% vs 10%). Fear of offending patients was of equal 
concern to male and female physicians, with approximately 
25% of each indicating this was a barrier. On average, female 
providers had asked more patients about abuse than had male 
providers (12% of patients vs 5%). 

Detection of abuse. Compared to only 15% of providers with 
no prior exposure, 31% of those who had been exposed to 
information about abuse felt confident in their ability to identify 
abused women. Only five of the 59 respondents (8%) said that 
they had a standard method or protocol for identifying abused 
female patients. Of these, two used their own judgment, two 
used methods they learned in their residency programs, and one 
had developed a method from readings and discussions on the 
topic of abuse. 



Discussion 

Providers say that they believe that detection of abused patients 
is an appropriate part of family practice, but those responding 
to this study asked very few patients about abuse and didn't 
believe abuse was a common problem among their patients. 
Almost surely these doctors fail to identify a large number of 
women who are victims of domestic violence. 

Respondents identified a number of barriers that impeded 
asking patients about abuse. Physicians with more exposure to 
information about abuse cited fewer obstacles, suggesting that 
educational interventions directed at providers may be useful. 
If so, provider education should take into account that male and 
female physicians perceive different barriers to asking about 
abuse. The use of recently developed practice protocols may 
help providers overcome their reluctance to address this prob- 
lem. 

Our study has limitations. It was conducted on a small, 
voluntary sample of providers, and there was only a 41% 
response rate. Consequently, the results cannot be generalized 
to the population of family practice physicians. However, this 
small study does suggest the value of examining the factors that 
influence providers' interactions with potentially abused women. 
Domestic violence is an important and serious health problem. 
We need lo find out whether active training on abuse (such as 
workshops or clinical rotations) is more effective than passive 
training (such as lectures or reading articles). The notion that 
there are gender and educational differences in physicians' 
responses to the issue of domestic abuse suggests the need for 
further investigation with implications for the development of 
intervention activities. □ 



Acknowledgments: The authors appreciate the contributions 
to this study by Vangie Foshee, PhD, and Pamela Frasier, 
MPH. 



References 

1 Hamberger KL, Saunders, DG, Hovcy M. Prevalence of domestic 
violence in community practice and rate of physician inquiry. Fam 
Med 1992;24:283-7. 

2 Rath GD, Jarratt LG, Leonardson G. Rates of domestic violence 
against adult women by men partners. J Am Board of Fam Pract 
1989;2:227-33. 

3 Bowker L, Maurer L. The medical treatment of battered wives. 
Women & Health. 1987;12:25-44. 

4 Hamilton B, Coates J. Perceived helpfulness and use of profes- 
sional services by abused women. J Fam Viol 1993;4:8. 

5 McLeer S V, Anwar R. A study of battered women presenting in an 
emergency department. Am J Pub Health 1989;79:65-6. 

6 Tilden VP, Shepherd P. Increasing the rate of identification of 
battered women in an emergency department: use of a nursing 
protocol. Res Nurs Health 1987;10:209-15. 



7 Rath GD, Jarratt LG. Battered wife syndrome: overview and 
presentation in the office setting. SD Med J 1990;Jan:19-25. 

8 Friedman LS, Samet JH, Roberts MS, Hudlin M, Hans P. Inquiry 
about victimization experiences: a survey of patient preferences 
and physician practices. Arch Int Med 1992;152:1186-90. 

9 Gremillion DH, Evins G. Why don't doctors identify and refer 
victims of domestic violence? NC Med J 1994;55:428-33. 

10 Brown JB, Lent B, Sas G. Identifying and treating wife abuse. J 
Fam Pract 1993;36:185-91. 

1 1 Sugg NK, Inui T. Primary care physicians' response to domestic 
violence: opening Pandora's box. JAMA 1992;267:3157-60. 

12 Ferris LE, Tudiver F. Family physicians' approach to wife abuse: 
a smdy of Ontario, Canada, practices. Fam Med 1992;24:276-82. 

13 American Medical Association. Physician Characteristics and 
Distribution in the US, 1993 edition. 



138 



NCMJ MaylJune 1996. Volume 57 Number 3 



• » 



'7 have a very select practice. 



DR. ARTHUR NXILLIAMS, DIRECTOR OF HEALTH SERVICES 
SOUTHSIDE HEALTHCARE, INC., ATLANTA, GA 



Dr. Williams doesn't see just anyone. 
Only those who need him most. 



^\ 





M 



As director of health services at 
Southside Healthcare, one of the 
nations five largest community 
health centers, Dr. Williams oversees 
a team of health care professionals 
that managed 153,000 patient visits 
last year. 

Dr. Williams' career reflects his com- 
mitment. He worked as a pharma- 
cist, then went back to school and 
earned his MD. He paid for medical 
school by committing to work three 
years at a community health center 
— Southside. Nine years later, he's 
still there, still giving. 



^i 



The Sharing the Care program 
donates Pfizer's full line of single- 
source pharmaceuticals to medically 
uninsured, low-income patients of 
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Southside, in support of those who, 
like Dr. Williams, are part of the cure. 



Sharing the Care: A Pharmaceuticals Access 
Program is a joint effort of the National 
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of Community Health Centers and Pfizer 




We're part of the cure. 



A PIECE OF 



NORTH CAROLINA DOCTOR'S MIND 



A Body To Die For 



Gregory J. Davis, MD 



I could not believe it, yet there she was, perhaps 40 yards ahead. 
I crept up Reynolda Road at a cold snail's pace. It was a frigid 
morning of 20 degrees, the sequela of the worst snowstorm 
since 1940. A treacherous veneer of ice dared mc not to drive 
above 20 mph, but there she was: a jogger rapidly approaching 
mc in the road. Furtive glances about me and quick calculations 
proved my fears: the ice-bound rut that locked my tires and the 
four- foot snowbank on either side of the road gave me a margin 
of error of perhaps one foot. Only one foot, the whim s of ice and 
snow, her footing, my skill as a driver, and the skill (or lack 
thereoOof all the drivers around us separated this young woman 
from dismemberment or death. 

What impels such an individual, 1 wondered. Why would 
she willingly put her life in such jeopardy for the sake of a jog? 
Narrowly missing her with my car, I drove on, my mind racing 
with questions while trying to "keep it between the ditches," as 
my wife, Kathleen, is wont to say. The young woman appeared 
to be in top physical condition and was obviously no stranger to 
exercise. I conjured up an image of her: an avid athlete, certainly 
careful about what she eats, checking nutrition labels on all her 
foods, eschewing store-bought victuals for "organic" 
consumables. Maybe she uses a calculator to keep track of all 
carbohydrates, proteins, fat, minerals, and calories entering her 
finely tuned body. Of course, alcohol and tobacco are strictly 
verboten. She is an active partner with her physician, bringing 
lists of questions and concerns so that she can more intelligently 
take part in her health care. It is, after all, her body. She is also 
a bit of a nervous flyer because, accustomed to feeling in control 
of every aspect of her life, she is loathe to place her life in the 
hands, however capable, of an airline crew. 

Why on earth would such a person place her life in the 
hands of passing drivers, strangers of whom she knows nothing, 
many of whom (we may assume) are distracted or still sleepy 
although most of whom (we hope) are licensed to drive? Does 
it not strike her as ironic that the twitch of a hand on the steering 
wheel, a sneeze, the bend of an irresponsible head to glance at 
a radio dial , can leave her maimed or dead? Does she not realize 



that the four-foot snowbank to her left will prevent her jumping 
out of the way of a skidding car? 

Plus ga change, plus c'est la meme chose.... Twenty years 
ago my college first-aid instructor, Dr. Jess Gardner, berated 
those of us who jogged in the road with the question, "Is getting 
in shape worth dying for?" The late ' 70s saw a boom in jogging; 
it also saw automobiles lowering the boom on many of those 
who chose to run in the road. G.E. Burch asked in \hQ American 
Heart Journal if we were exercising to health or to death;' A.F. 
Williams of the Insurance Institute for Highway Safety called 
for common sense on the part of both drivers and joggers.^ 
Common sense, sorely lacking in the young jogger I came 
across, was the constant admonishment of Mr. Noe, my wife's 
high school driving instructor: "Always leave yourself a way 
out." Advice as applicable to jogging as to driving. 

The young woman's judgment may have been clouded by 
exercise-induced euphoria, a phenomenon not unknown to this 
former cross-country runner. Collisions between joggers and 
motor vehicles have been blamed on such a state,' though at 
6:30 on such a cold morning, euphoria is not \.\\c first state that 
comes to mind. Perhaps it is the national obsession with 
appearance that has clouded our minds? It certainly has clouded 
our priorities. We read ad nauseam in journals, magazines, and 
newspapers of the fake fats soon to join our fake sweeteners, of 
which we consume tons to slim down while much of the world 
remains hungry. It is not politically correct in our culture to 
admire someone for his or her looks or body. Instead, we pay lip 
service to seeing the "inner person," but never before have we 
worked as long, sweated as hard, dropped as many dollars, or 
risked as much in our attempts to look like the American 
"ideal," thecachec tic supermodel. Thecartoon on my colleague's 
refrigerator door says it all: two aging, portly dowagers stand 
above a svelte woman in a coffin, looking down upon her. 
Woman #1: "You know, I heard it was one of those new diets 

that killed her." 
Woman #2: "Yeah, but doesn't she look terrific in that size 6 
dress!" □ 



Dr. Davis is Assistant Professor, Department of Pathology, 
Bowman Gray School of Medicine, Medical Center Boulevard, 
Winston-Salem 27157, Medical Examiner, Forsyth County, and 
Regional Forensic Pathologist, State of North Carolina. 



References 

1 Burch GE. Of jogging. Am Heart J 1979;97:407. 

2 Williams AF. When motor vehicles hit joggers: an analysis of 60 cases. 
Pub Health Rep 1981;96:448-51. 

3 Shephard RJ. Vehicle injuries to joggers: case report and review. J 
Sports Med Phy Fitness 1992;32:321-31. 



140 



NCMJ May/June 1996, Volume 57 Number 3 



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THE TEACHING AND LEARNING OF MEDICINE 

Medical Education and 
Health Care Reform 

From Osier to AHEC 

William O. McMillan, Jr., MD, FACP 



Exploding costs of health care delivery, new and expensive 
technology, government mandates, pressures from the tort 
system, and a distinct message from corporate America have all 
converged to reform our health care delivery system. As a 
result, medical education must also change. Both the public and 
private sectors are pressing to decentralize the educational 
endeavor beyond the walls of the university /hospital complex. 
What can doctors of today learn from our colleagues of the past 
century as we prepare for the changes of the 2 1 st century? Can 
we maintain the positive values attained by medical education 
since the Flcxner Report? Can Osier ' s basic educational tenet — 
the personal contact of student and patient — be translated from 
a university hospital setting to an ambulatory, "managed care" 
environment? 

I want to look back to the turn of the present century and 
review some of the problems William Osier and his contempo- 
raries encountered. American medical education then was in 
disarray. The country had seen the development of proprietary 
medical schools that functioned like trade schools with periods 
of apprenticeship. A total of more than 450 proprietary schools 
were created, but many closed' so that by 1907 "only" 160 were 
in operation.^ Little attention was paid to premedical education; 
often, a high school diploma or less was sufficient for matricu- 
lation. Commercial advertising solicited unsophisticated Ameri- 
can youths to pursue a career in medicine.' 

In 1910, the Carnegie Foundation Report on Medical 
Education in the United States and Canada "turned the light 
upon conditions which, instead of being fruitful and inspiring. 



Dr. McMillan is Executive Director, Coastal Area Health Educa- 
tion Center, 2131 S. 1 7th St., P.O. Box 9025, Wilmington 28402, 
Vice President for Graduate Medical Education, New Hanover 
Regional Medical Center, Wilmington, and Clinical Professor, 
Department of Medicine, UNC School of Medicine, Chapel Hill. 
He presented this paper during the American Osier Society's 
meeting at the University of Pittsburgh, May 10-11, 1 995. 



were in many instances commonplace, in others bad, and in sdll 
others, scandalous."' The Carnegie Report took direct aim at the 
commercial or proprietary schools, including one in Charlotte 
described as "containing a poor chemical laboratory, contain- 
ing one set of reagents, and a wretched dissecting room...."' 
The University of North Carolina was actually complimented 
because its admission standards were deemed "higher than they 
probably ought to be at this time." The report suggested that 
application of similar standards "would quickly dispose of the 
thoroughly wretched Charlotte establishment."' 

In his introduction to the Carnegie Report, Henry Pritchett 
said that the lack of educational and professional standards 
were moral issues that needed addressing by the universities 
and the medical profession. These two bodies had been given 
considerable societal trust to act in the best interest of the health 
needs of the country. Pritchett felt it was the educational duty of 
the universities to champion intellectual honesty and scientific 
accuracy. This mission superseded the attraction of a large 
paying student body or the attaining of institutional complete- 
ness. As a result, no university should be involved with medical 
education undl it could oversee its academic program and 
support it as fully as any other degree -gran ting program . Pritchett 
exhorted the medical profession to put the care of the patient 
above personal or professional gain.' Clearly, medical educa- 
tion had reached a deplorable state all over the country and 
change needed to occur. 



Osier's Response 

Osier recognized and addressed these educational problems 
while teaching in Montreal, Philadelphia, and Baltimore. Of 
interest, proprietary schools first began in Baltimore and were 
quite abundant by the time Osier arrived there in 1889.' At 
Johns Hopkins he labored to develop "a subUe and ponderable 
element, a sort of educational radium, an emanation not easy to 



142 



NCMJ May I J one 1996. Volume 57 Number 3 



analyze known as the university spirit."^ Fortunately, the impe- 
tus was already present for grounding medical education in 
science. Osier involved the hospital and the university by 
having a well-defined unit for bedside teaching of the student. 
In so doing. Osier was influenced by European medical schools 
which became his models for the development of a science- 
based practice of medicine. He expressed his thoughts about 
medical education in a 1903 address titled "The Hospital as a 
College."" But change did not proceed smoothly. "Unrest and 
change are the order of the day," Osier said in his address to the 
Abenethian Society of London in 1913.^ Osier also expressed 
his views in the final report of the Royal Commission on 
University Education in London.' This paper is not signed by 
Osier, but Cushing felt he was the author of the section on 
London University reform.' As the London Quarterly Review 
put it, "It is hard to put new wine into old bottles; it is hard to 
organize and update medical faculty with the conditions at 
present prevailing in London; but it is not impossible. Wedded 
to the old order, some men are as oblivious of the changes going 
on about them as to the alterations they see daily in their glass 
but do not recognize. There is a new outlook in medicine, and 
a new science is molding both thought and practice. Vested 
interests are powerful, old associations and ways are strong, but 
stronger still we hope, will be the public and professional 
opinion and favor the changes suggested by the commissioners. 
London should be the most important medical center in the 
world, but it is not. This is due to lack of organization and 
cohesion. To unite its scattered forces into a great faculty is one 
aim of this able and far reaching report which will have the 
active support of all but those whom fear of change not only 
perplexes but appalls."' 

Reform, indeed, took place, to some extent emanating from 
the universities, but mainly from the physicians themselves 
through state boards and foundations like the Carnegie Founda- 
tion for the Advancement of Teaching.^ The involvement of 
hospitals with medical education has since been pursued with 
great vigor by academic health centers. Since World War II, 
university teaching hospitals have become large teaching enter- 
prises. Faculty practice plans, government and private research 
grants, and other federal and state incentives funded these 
endeavors, but in their expansion they have become expensive 
and not well structured for change. 



Health Centers' Education Mission 

Now, more than 80 years later, we face another crisis in 
academic medicine. At the meeting of the American Associa- 
tion of Medical Colleges in 1995, the Association president, 
Jordan Cohen, said: "We in academic medicine are more 
concerned than ever about the future of our enterprise."' And 
with good reason! The failure (for the present) of federal health 
care reform, means that the educational enterprise will be 
severely tested by a variety of public and private forays into 
managed health care. The changes will not be kind to the 



cumbersome academic health center. Change will occur, but 
how? And will we sacrifice the academic health center's 
mission of education, research, and service? I want to look here 
at only the educational mission. 

Osier often repealed his beliefs that a good medical educa- 
tion consisted of the following: 

• A pre-medical student well-prepared in basic sciences and 
proficient in a foreign language, like German or French. 

• A patient-oriented medical education that used hospital 
wards as laboratories. 

• A close association of a hospital with a university so that it 
will be imbued with the university spirit. 

• An academic faculty of physicians (not necessarily full- 
time teachers) to insu"uct the medical student. 

• The presence of well-established and maintained clinical 
and pathological laboratories, and a library. 

Osier's views about medical education are as important to 
us as they were in the early 1900s. Even as it changes, medical 
education still needs a strong scientific basis that ties hospital to 
university. Osier's emphasis on the importance of a close 
relationship between the doctor and patient is even more 
pertinent in today's world of high technology and specializa- 
tion. Osier's values can be maintained, even taken another step 
forward as medical education is accommodated to an ambula- 
tory setting. 

Today's mandate for medical education in an ambulatory 
setting should encompass the following goals: 

• While keeping its university affiliation, medical education 
should be community-based and encourage generalism. 

%/ Medical education should promote prevention and wellness. 

• Medical education should be problem-based not curricu- 
lum-based. 

• Medical education should encourage working in teams and 
collective decision-making. 



AHECs: Partnerships for 
Health Care Reform in NC 

North Carolina's approach to health education reform is being 
addressed through the Area Health Education Center system. In 
1 970, 60 years after the Flexner Report, the Carnegie Commis- 
sion on Higher Education suggested the formation of 126 Area 
Health Education Centers (AHECs) throughout the country to 
encourage better distribution of physicians and other health 
care personnel. AHECs were to be university sponsored, but 
removed from university centers to improve access to health 
care.' In 1972, the federal government funded the initiative 
outlined by the Carnegie Commission of Higher Education 
under Title VII. North Carolina was one of 1 1 states given 
grants based at university schools of medicine. In 1974, the 
State of North Carolina funded a statewide AHEC program in 
cooperation with the state's four medical schools. The Univer- 
sity of North Carolina at Chapel Hill has responsibility for 
directing the program. 



NCM J May /June 1996, Volume 5 7 Number 3 1 43 



In North Carolina, AHECs represent a partnership between the univer- 
sity health science centers and the community. They are a part of a medical 
school and provide education and training for health professionals. Six 
AHECs arc affiliated with the University of North Carolina in Chapel Hill: 
Area L, Charlotte, Coastal, Greensboro, Mountain, and Wake. Duke spon- 
sors the Fayettevillc AHEC; Bowman Gray, the Northwest AHEC; and East 
Carolina University, the Eastern AHEC. Each AHEC serves the several 
counties in its area so that all North Carolina counties are covered. In 1994- 
1995, the state appropriated $36 million for the AHEC program, and an 
additional $68 million came from local contributions. In 1993- 1994, AHEC 
programs provided 1 ,425 student-months (one student for one month) of 
education in allied health; 1,414 in nursing; 222 in dentistry; 675 in 
pharmacy; 3,652 in medicine; and 342 in public health. 

Recently, to meet the new demands of undergraduate medical educa- 
tion, each AHEC developed an Office of Regional Primary Care Education 
(ORPCE) which will coordinate a program to get medical students and other 
health professional students into more rural and other underserved areas. 



Support of Student and Community 

Does our present system meet the educational reform championed by Osier 
a century ago? The university remains in the picture albeit at a distance, and 
so does "the university spirit." Students today arrive at medical school well- 
prepared in the basic sciences and mathematics, and with an understanding 
of informatics. Now, medical students follow the patient outside of the 
hospital where the new delivery system dictates evaluation and care should 
take place. AHEC-based student rotations, primary care residency training, 
continuing education, and information services are supported by 180 full- 
time medical faculty and almost 800 other health professionals and staff. 
AHECs provide faculty development and compensation for community 
practitioners. The student remains connected to libraries and electronic 
databases by computer. The system is evolving into what we now call Phase 
II of the North Carolina AHEC statewide system, but with strict attention to 
the educational goals articulated by Osier 100 years ago. North Carolina 
Area Health Education represents our attempt to place new wine into old 
bottles in hopes that wc will not be perplexed or appalled by the change in 
medical education. □ 



References 

1 Flexner A. Medical Education in the United States and Canada. New York: 
Carnegie Foundation for the Advancement of Teaching, 1910. 

2 Howell W. Memorial of the Centennial of the Yale Medical School. New Haven, 
CT: Yale University Press, 1915. 

3 Gushing H. The Life of William Osier. London: Oxford University Press, 1925. 

4 Osier W. Aequanimitas with Other Addresses, 3rd ed. Philadelphia: Blakislon, 
1948. 

5 Medical Education in Europe: A Report to the Carnegie Foundation for the 
Advancement of Teaching. New York, 1912. 

6 London University Reform. London Quarterly Rev 1913;219:230. 

7 Cohen J. Finding the silver lining without the golden eggs. Academic Medicine 
1995:70:98-103. 

8 Carnegie Commission on Higher Education. Higher Education and the Nation's 
Health Policies for Medical and Dental Education. New York: McGraw Hill, 
1970. 



Applause for 
AHEC and Osier 

W. Randolph Chitwood, Jr., MD 



Dr. McMillan has taken the high road In 
discussing the conflicting goals faced by medi- 
cal education during these trying times of 
"health care revolution." He has addressed 
the basic exigencies faced by medical edu- 
cators of an earlier day and drawn compari- 
sons. Had Sir William Osier been a time- 
traveler, he would find — In community and 
hospital alike — that the ward doctor in a long 
waistcoat of his day has been replaced by a 
technologically more adept physician today. 
But Osier's grasp of the basics In medical 
education could still be applied to our time. 

Dr. McMillan Is concerned about the 
education of physicians as we move away 
from a centralized hospital-university envi- 
ronment of Osier's time to primary care and 
non-specialty practice sites. Before Osier, 
medical education was often based on em- 
piricism and antidote, with the result being an 
unskilled practitioner. Osier's efforts helped 
make the patient the central focus of educa- 
tion, but clearly in a university and teaching 
hospital setting that led eventually to intense 
and sometimes narrow specialization. Now 
we are returning toward a more generalistic 
approach to care, but we must rememberthe 
wisdom of Sir William as we sculpt a plan for 
educating our young doctors and nurses. I 
find it interesting that the watchwords in my 
hospital today are "patient-focused care" and 
"work redesign." Sir William would have wept 
to hear that along the way these tenets had 
crept so far away that today there is a need to 
recapture them. 

Dr. McMillan's four-point plan for future 
medical education is well considered, but I 
believe that we must not depart totally from a 
structured educational plan based in a hospi- 
tal-university setting. I think that specialized 
care will continue to be a major part of patient 
care in the future because medical problems 
are more complex than ever, and we are an 
aging population. Having been involved 
closely through my family with three genera- 
tions of true generalist physicians, I have 
heard my father lament the lack of special- 
ized care; I have also seen him and his 
colleagues handle comfortably and with com- 
petence many patients who are now referred 



144 



NCMJ May /June 1996, Volume 57 Number 3 



for expensive specialist care without added benefit. We must 
find the successful blend. After all, our technologic age 
provides benefits not dreamed of by the generalist even five 
years ago. 

Direct contact with universities and teaching facilities 
through facsimile transmissions, telemedicine, and Internet 
communications can and will put physicians "on-line" with live 
consultation and continuing education. We will thus provide 
community-based education to medical students and resi- 
dents — and to practicing physicians — better than ever be- 
fore, at the same time keeping most of our patients "on-site" 
and accessible to economical care. This will mean a new 
challenge for the generalist practitioner, afield from the 
university setting. The generalist will have to take on the 
same shroud of responsibility for teaching as the university 
professor. Likewise, it will be a challenge for the specialist to 
assure the presence of generalist input so that, by collective 
decision, they render the most appropriate specialized care. 
Both generalists and specialists must be involved in the 
community-based education of all health care providers. 

We are moving toward collective and team decision- 
making, but we must be sure that each patient has a "Doctor." 
Eugene Stead, the mentor of so many residents and students 
at Duke University, often said that "What this patient needs 
is a doctor!" So must we be sure that each patient has a 
focused physician advocate, who can process and proffer 
any team-derived plan to the patient and renderthat essential 
part of medicine called "caring" along with cure. Clearly, there 
is no better way for a doctor to help us make the necessary 



investments in prevention and wellness than through a 
community-based approach. 

I believe that Sir William would be proud that physicians 
today are taking a proactive and responsible role, asking 
difficult questions about optimal medical education for the 
future. I agree with Dr. McMillan that our North Carolina 
AHEC system provides the nation with a model for regional- 
ized medical education. Community-based medical educa- 
tion, supported by North Carolina AHEC and university 
programs like the Generalist Physician Program at the East 
Carolina University School of Medicine, is leading the way for 
the nation. Congratulations North Carolina! A protege of 
Osier once said of him, "Today the student assumes lightly 
that medical education has always been thus... not realizing 
what a revolution in teaching this was and what an everlast- 
ing debt of gratitude [the student] owes to this great physi- 
cian." Similarly, our job is to provide a map for community- 
based medical education and service, just as it was for Osier 
and Flexner a century ago. But we must proceed cautiously. 
We must preserve specialized advances and treatment 
discoveries, applying them appropriately through communi- 
cations and teamwork. As the millennium approaches, our 
"waistcoats" will seem to lengthen in the eyes our succes- 
sors. We must be sure that those successors smile on our 
wisdom and the reverence we hold for Sir William's vision. □ 

Dr. Chitwoodis Professor and Chief, Division of Cardiotfioracic 
Surgery, East Carolina University School of Medicine, 
Greenville. 






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Climetick: "The MICU" 



Victor F. Tapson, MD 



The M-l-C-U* is the place, 

Where you go when you have a bad case 

Of pneumonic infection, 

Or Type III dissection. 

Or a cancer that's picked up its pace. 

Thanks to a guy named Foley, 
A catheter's there for your pee. 
Once that tube's in its place, 
And a few in your face, 
We might place one rectally. 

When you arrive you will get an A-line, 

To be sure that your pressure is fine 

In your wrist or armpit. 

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Boredom Is not a concern. 

There's lots of stuff there to learn. 

Like every last spot. 

That the ceiling tiles' got, 

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Of Duke getting beaten by Wake. 

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Then the channel that's on. 

Is the one of which you'll partake. 

Gl bleeders will get more melenic. 
If on aspirin or thrombocytopenic. 
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And endoscopy will be more scenic. 

A hemorrhoid may not be a big thing, 
A spot 'round your butt that might sting. 
But if one bleeds a lot. 
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In the MICU's Center Ring. 



And if you should get an impaction, 
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You will find out which nurses are sane, 

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Of Ativan's close 

To enough to sedate a blue whaie.§ 

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A mother and very best friend. 
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So when death looks you straight in the face. 

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* Pronounced "Em I See You" 

t Any of a genus of mostly poisonous herbs with milky juice 

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of the work. Our patients love them too. 
§ The largest animal ever to inhabit the earth. 



Dr. Tapson, creatorof clinical limericks, is Assistant Professor, Division of Pulmonary and Critical Care Medicine, Box31175, 
Duke University Medical Center, Durtiam 27710. 

V ^ 



146 



NCMJ MaylJune 1996, Volume 57 Number 3 







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THE TEACHING AND LEARNING OF MEDICINE 

A New Paradigm for 
Continuing iViedicai Education 

Implications for North Carolina in an 
Age of Change in Health Care Delivery 

James C. Leist, EdD, William E. Easterling, MD, Susan Gustke, MD, Thomas E. Sibert, MD 



The national health care system is changing. Patients are being 
asked to accept more responsibility for their health and well- 
being. Business and industry, having weighed the cost of health 
care, have decided to decrease the percentage of their budget 
they spend on that item. Physicians are increasingly consider- 
ing how much care costs the patient. Finally, physicians are 
em.phasizing the role of prevention and health promotion in 
their practices. These issues have significant implications for 
the continuing education of practicing physicians. 

Continuing medical educators must review the services 
and products they provide and the way those services or 
products are offered. Without doubt, teacher-directed, lecture- 
based continuing medical education (CME) will continue, but 
a new model is evolving. It requires CME activities to be based 
on verifiable clinical data, be team-oriented, emphasize the 
enhancement of quality of care, produce specific educational 
and health care outcomes, and be directly intcgrable into the 
health care system. In this model, learners actively design their 
own learning program based on an evaluation of their practice 
patterns and the type of system (fee-for-scrvice or managed 
care) in which they work. Moore et al' outlined the factors 
affecting the transition to this new model and suggested some 
creative ways to approach CME. This model forms the basis for 
this review, and the framework for our suggestions about how 
we might use the new CME paradigm. 



Traditional CME 

Unul the past 10 years, medical student training and CME were 
formulated similarly. Now, the introduction of problem-based 



learning into medical schools has influenced the development 
of a new paradigm for CME, too. Traditionally, CME uses 
lectures to provide faculty-determined teaching activities. This 
approach only minimally affects physician behavior or patient 
outcomes. In 1992, Davis et aF found that traditional CME was 
effective only when learners were involved in developing and 
implementing the CME activity. Traditional (and most current) 
CME activities afford only minimal collaboration between the 
learner and faculty in planning the CME activities. Conse- 
quently, the activities do little to meet learners' needs in a timely 
way.' The "teachable moment" — the occasion when the learner 
needs and can use information to make a decision or take an 
action — is missed, making it unlikely that the taught informa- 
tion or skill will be incorporated into future practice. 

Until now, emphasis was placed on offering CME "cred- 
its" rather than on the outcomes of the educational activity. 
Providers gauged their success by how many people enrolled 
rather than what those people learned. B ut despite its shortcom- 
ings, traditional CME will continue because it provides practi- 
tioners with 1) a method for updating their practice when new 
knowledge becomes available, and 2) a validation of individual 
practice with the current standards of practice. 



Forces Creating Change in CME 

Government and private sectors are scrutinizing the tremen- 
dous costs of health care and raising serious questions about the 
effectiveness of that care. Govemment has been less of a driving 
force than estimated, but business and industry continue to 
instigate change. They have turned to managed care as a means 



Dr. Leist is Associate Dean for Continuing Education, Bowman Gray School of Medicine, Winston-Salem; Dr. Easterling is 
Associate Dean for Continuing Medical Education and Alumni Affairs, UNC-Chapel Hill School of Medicine, Chapel Hill; Dr. Gustke 
is Associate Dean for Continuing Medical Education, East Carolina University School of Medicine, Greenville; and Dr. Sibert is 
Associate Dean for Continuing Medical Education, Duke University Medical Center, Durham. 



148 



NCMJ May /June 1996, Volume 57 Number 3 



of providing health care for their employees at a reduced cost. 
These economic forces affect the nature of CME offerings. 

A second force creating change is the application of quality 
improvement techniques by health care institutions. Leaders of 
those institutions want to know that what they do is effective 
and whether it yields a service of appropriate quality. 

A third force is the continuing expansion of biomedical 
information and technology. Physicians must update things 
they learned five years ago and must alter their practices if they 
want to stay up to current standards of practice. 

Finally, there is the advance of information and communi- 
cations technology. It is possible to promote more effective 
communication between health care providers, between practi- 
tioners and CME educators, and between practitioners and 
patients. 



A New CME Paradigm^ 

The forces — health care reform (economics), quality manage- 
ment, biomedical advances, and enhanced communication tech- 
nology — that make practitioners and CME providers think 
about their products and services, also produce an environment 
for change. We expect that CME will become an integral part 
of the health care system. CME educators have long been 
shunted to the margin of the health care system and have not 
regularly been a central part of the organization. The overriding 
outcome of the new model is to make CME an integral part of 
an effective health care system. As the health care system 
struggles to produce quality-oriented, cost-effective providers, 
CME that focuses on clinical, economic, and management 
issues will be necessary. 

An even more important outcome of the new model is its 
emphasis on learning, and the application of learning, rather 
than teaching. CME providers already promote this character- 
istic: the American Medical Association now gives a Physician 
Recognition Award certificate with "special commendation for 
self-directed learning," and Dr. John Parboosingh of the Royal 
College of Physicians and Surgeons of Canada has developed 
the Maintenance ofCompetence Project (MOCOMP). In 1996, 
MOCOMP will be piloted by the four North Carolina medical 
schools, the only sites outside of Canada where the program 
will be available to practicing physicians. 

Another characteristic, and the basis for, the paradigm is 
that educational activities will be based on clinical outcomes 
data and collaborative planning with the practitioner. If the 
health care system is to recommend treatment based on the 
expectation of improved patient outcomes, then CME must be 
based on data that document improved health status of patients. 

A fourth feature is the blending of quality management 



with CME. This complicated aspect involves the application of 
continuous quality improvement techniques to the learning 
process. Physicians understand how this process works in terms 
of the health care system, but it will be a challenge to implement 
it within CME. 

A fifth characteristic is the introduction of a collaborative 
and responsive learning system involving both the physician 
learner and the CME provider. The model calls for learner and 
provider to work together, analyzing what needs to be learned 
and why, then determining the most effective way to reach the 
desired outcome. CME content would not be presented exclu- 
sively in its traditional manner, because CME providers will 
become facilitators of learning instead of mere program provid- 
ers. 

The final characteristic of the new method is its focus on 
improving patient outcomes. We can anticipate that the future 
health care system will monitor patient care outcomes closely. 
CME providers will need to work with individuals and groups 
of physicians to design educational interventions that will 
change practice behavior when indicated and document im- 
proved outcomes. 



CME in North Carolina 

This CME paradigm has implications for North Carolina. 
Anticipated changes include: 

• Traditional CME will be used to present new knowledge and 
to validate individual physicians' standards of practice, but it 
will emphasize cost-effective decisions and prevention as con- 
stant content themes. 

• The AHEC system, medical schools, and the North Carolina 
Medical Society will implement new, learner-oriented, out- 
comes-based CME. 

• CME providers will develop alliances with managed care 
organizations and group practices to emphasize health status 
outcomes of their patients. 

• CME providers and physicians will need to learn how to 
measure outcomes and seek successful educational interven- 
tions to improve them. As a corollary, we will need to agree on 
community-wide standards of practice and desirable outcomes. 
*^ Communications technology will permit individualized 
learning and link practitioners with teaching/learning resources 
at the point of health care delivery. 

The new paradigm will operate simultaneously with the 
old, yet keep CME in line with changes in evolving health care 
systems. The model will move CME toward a personalized 
program for North Carolina's practicing physicians centered on 
improving patient care outcomes. □ 



References 

1 Moore DE, Green JS, Jay S J, Leist JC, Mai tl and FM . Creating anew 
paradigm for CME: seizing opportunities within the health care 
revolution. J Com Educ Health Prof 1994;14:261-72. 

2 Davis DA, Thomson MA, Oman AD, Haynes RB. Evidence for the 



effectiveness of CME. JAMA 1992;268:11 11-7. 
3 Davis DA, Fox RD. TTie physician as learner. Chicago: American 
Medical Association, 1994. 



NCMJ May/June J 996, Volume 57 Number 3 1 49 



Commentary 



Margaret N. Marker, MD, Journal Editorial Board Chair 

The discussion by Drs. Leist, Easterling, Gustke, and 
Sibert got me to thinking about "teachable" moments. 
Such moments indeed exist in medicine, and we must 
continually look for and take advantage of them, espe- 
cially in this era of evolving medical practice and CME 
programs. It seems to me that the end result of what 
teachers teach and students learn translates into out- 
comes that ensure the safety of our patients. 

Do not teachers help us maintain our balance and 
center? Isn't their goal to load the vessel of our mind with 
knowledge so that we can practice with the same? If so, 
good education should let us "sail straight," serving our 
patients as both protector and advocate. That ought to be 
the goal of teaching and learning. 

I agree with Leist et al that communications technol- 
ogy — computers, fax, telemedicine, and the like — can 
help physicians. But no amount of automation will replace 
clear thinking and careful caring. We should cautiously 
investigate new trends in education, emphasizing clear 
and rigorous thinking instead of rushing after what's "new" 
or trendy, until proven worthwhile. 

For a number of years I worked in academic medi- 
cine, giving lectures to rooms full of students. Once, 
before a talk on breast examination, I recall scanning the 
conference room: coffee cups strewn everywhere, news- 
papers scattered about, snoozing students, lots of idle 
chatter. I made the unpopular request that those who 
wanted to be somewhere else should leave. I then at- 
tempted to offer some hands-on experience by asking the 
students to locate fake breast lumps hidden in fake 
breasts. Only a few even tried. A miserable failure in the 
lecture room, I found more success during clinic and pre- 
clinic conferences. 

Ideally, the distinction between teacher and student 
should be blurred. Doctors should always remain stu- 
dents, sharing our varied talents and experiences with 
colleagues. I once asked a Cf^E program director to send 
the university faculty into outlying doctor's offices for half 
the program and assign the other half to lectures and slide 
shows. There were no takers. 

I entered the study and practice of medicine full of joy 
and enthusiasm, both of which are hard to come by these 
days. It is our duty as physicians to help each other bring 
them back. Recently I laid my head on my desk, ex- 
hausted from overwork and frustration. Then I got up, 
went to the emergency room to tend to some sick folks, 
which I found oddly soothing. 

Dr. Leist and his co-authors raise some gems of ideas 
about continuing medical education. We should imple- 
ment them — not study them or write them up as grant 
proposals — but really put them into action. CME should 
take advantage of every educational moment, always 
keeping the center and balance of medical practice in 
perspective. □ 



Combat on the 
Tenth Floor of a 
Veteran's Clinic 

Edward V. Spudis, MD 



Wfiat to tell this new doctor wearing tennis shoes, 
watching him unfold my stapled brown chart the 
size of three Chicago phone books? 

Predictable pain for 50 years, always at night, mo- 
mentary but intense. Visions of Walker's intes- 
tines, every few minutes every day for decades, 
in my lap and on the window, his spleen like a 
purple summer squash. So, I got specks of 
ticket-hcme shrapnel, spared because of a slight 
move I made, a twist, a premonitory slump. 

Last year I visited Sweden's Drottingholm Palace. 
The drawing room murals show 16th-century 
generals up front in fanciful, triumphant battle 
lines. Everybody was at the front then, and the 
king could tell the artists exactly where a king 
should be, thrusting his royal pike. 

In '45 I was 300 years more civilized, driving a new 
Jeep, near the front, or parallel to one, not mano 
a mano but only one seat from Jim Walker's 
front. Walker died in combat; I was 1 splattered 
inches away. His spleen and guts died first, then 
the family images, then scenes from Houston. 
Oppenheimer won the war, but not in combat, 
never mano a mano. 

I should have gone back, then. I needed to go back. 
I tried to go back. Brain cells stuffed with crinkled 
molecules of anger stay poised forever, like tiny 
cortical batteries of gelatinous hatred. Who needs 
black-and-white newsreel footage of the Solo- 
mons? 

Every month or so, in the foyer, as we shake the 
preacher's hand, or maybe after vespers, I hear 
young whispers behind me, ..."like, you know, 
exploded in the belly of the guy beside him." 

And, what is this skinny doctor thinking? "I know you 
were in the military, doc. Were you in com- 
bat?" □ 



Dr. Spudis is a neurologist at Forsyth Memorial HospitctI, 
Winston-Salem, and Clinical Professor Emeritus at Bow- 
man Gray School of Medicine. He resides at 1215 York- 
shire Road, Winston-Salem 27106. 



150 



NCMJ May, 'June 1996, Volume 57 Number 3 



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? ^ NORTH CAROLINA MEDICAL SOCIETY 

Health Watch 




RECYCLING LIFE 

by J. Dale Simmons, MD 



Hundreds of residents die every year in North Carolina while 
waiting for human organ and tissue transplants. This year 
most of those waiting will not receive a transplant and sadly, 
will succumb to disease before the needed organs and tissues 
are available. Even sadder is the fact that the needed organs 
and tissues could be made available and most likely would if 
the donation process was understood. 

Transplant patients' quality of life is usually greatly 
improved and, in most cases, the transplant itself is the 
difference between life and death. In addition, it is becoming 
cost effective in many cases to provide transplants. Statistics 
show that approximately 68% of all kidneys are functioning 
effectively three years after transplantation due to improved 
techniques and better medications. The cost of kidney 
dialysis, the alternative to transplant, averages $35,000 per 
year and the break-even cost of the transplant occurs approxi- 
mately 2 1/2 years after the transplant. 

J. Dale Simmons, MD, is Director of the Division of Health 
Promotion with the North Carolina Department of Environ- 
ment, Health and Natural Resources, Raleigh. 



Sixty-seven percent of transplants are paid for with tax 
dollars, so there is considerable savings if more kidneys, the 
most common organ transplanted, were available. By the 
year 2000 and thereafter, the North Carolina Organ and 
Tissue Program hopes that every North Carolinian requiring 
a transplant will have that opportunity within a medically 
sound period of time. In 1994, 236 kidneys, 72 hearts, three 
heart and lung combinations, 43 lungs, 84 livers, and 20 
pancreases were transplanted in North Carolina. These are 
the organs being transplanted today. 

Also in 1994, 854 corneas were transplanted. Although 
458 organs and 854 corneas were transplanted, 1 ,049 people 
remained on the waiting list for organs — and 50 for corneas. 



Encouraging Donations 

Not only are the organs and tissues mentioned here being 
transplanted, but skin, bones, ligaments, and heart valves also 
can often greatly improve the quality of life. Sight can be 
restored with corneal transplants; bone transplants can pro- 
vide an alternative to limb amputation; skin grafts can often 



NCMJ May/ June 1996, Volume 57, Number 3 



153 



save the lives of severely burned victims. Sixteen thousand 
people in the United States need kidney transplants, while 
across the country thousands more wait for other organs and 
tissues. 

We must encourage donation if we are to meet the 
demand for organs and tissues. Last year there were 5,027,391 
licensed drivers in North Carolina. Of those, only 720,549, 
or 1 4% indicated a willingness to be an organ donor. In 1 99 1 
in North Carolina, 1 ,064 persons were on the waiting list for 
organs. There were 99 donors during this same period; 
however, 54 people died while on the waiting list. Also in 
1991, 181 brain deaths were reported, which represented a 
potential 1,629 organs or corneas that could have been 
transplanted. 

Anyone can sign a donor card regardless of physical 
condition. Physicians determine the suitability of donated 
organs or tissues for transplant at the time of death. You must 
be at least 18 years of age in order to sign a donor card; 
however, persons under 1 8 may sign a card if their parents or 
legal guardians witness the signature. 



Carry Your Card 

Once you have signed a donor card, you should carry it with 
you in your wallet. It is important to tell your family your 
decision to become a donor. At the time of death, family 
members will be asked for consent for donation. It is also 
wise to inform both hospital personnel and your personal 
physician of your intentions. 

Donor and recipient information is entered into a nation- 
wide computer database. The computer matches the compat- 
ibility of the donors and potential recipients. Organs and 
tissues are shared locally, regionally, then nationally if there 
are no local or regional recipients. Social and financial 
considerations are not factors in recipient selection. 



For the thousands of Americans who 

have been stricken with end-stage 

organ failure, transplantation offers a 

second chance at life. 



Authorities of nearly all major religions and ethical 
systems have sanctioned organ donation. If there are doubts, 
a clergy member should be consulted. Donation is consid- 
ered only after all efforts to save a donor's life have failed. 
Criteria for death are strictly adhered to in making the 



determination of a potential donor. The family of the de- 
ceased donor remains responsible for funeral arrangements, 
but the organ procurement organization is responsible for any 
expenses associated with organ or tissue donation. The 
appearance of the body for burial is not affected, and funeral 
arrangements are not delayed. 

Uniform donor cards can be used to designate whether 
all, or only specific, organs and tissues are allowed to be used. 
Non-donors may become donors by completing a donor card 
(at the end of this piece) and notifying family members or a 
guardian. You can always change your mind about being an 
organ donor. Simply tear up the card and again notify your 
family members or a guardian. 

All states now participate in organ and tissue donation. 
So if a person should die out of state, their wishes can still be 
fulfilled. By carrying a donor card or indicating a desire to be 
a donor on the driver's license, medical personnel anywhere 
are aware of the bearer's wishes. 



Procurement Agencies 

In North Carolina, three organ procurement agencies handle 
organ procurement and disposition. They are: 

Carolina Lifecare 

Medical Center Boulevard 
Winston Salem, NC 27157 
Telephone: (800) 833-3002 

Carolina Organ Procurement Agency 

702 Johns Hopkins Drive 
Greenville, NC 27834 
Telephone: (800) 252-2672 

Lifeshare of the Carolinas 

PO Box 32861 
Charlotte, NC 28232-2861 
Telephone: (800) 932-4483 

The Eye Bank of North Carolina, located in Winston- 
Salem, processes and grades the tissues, and distributes 
corneas for use. All other tissues (bones, skin, heart valves) 
are handled through the three organ procurement agencies. 
The Eye Bank of North Carolina can be contacted at (910) 
765-0932. Organs and tissues are tested for HIV infection, 
syphilis, hepatitis B, and hepatitis C. They are discarded if 
the results of any of these tests are positive. 

One hundred people died while waiting for transplants in 
1994, compared with 70 in 1993. The number of donors 
increased from 1 09 in 1 993 to 1 40 in 1 994, but the number of 
people waiting for transplants increased from 934 to 1,100. 
In recent years, the number of potential recipients has in- 



154 



NCMJ May/June 1996, Volume 57, Number 3 



creased three times faster than the supply of available donors, 
so we must increase the donor pool if we are to reach our goal 
of an organ for every potential recipient. 



More Donors Needed 

Transplantation of whole organs from one person to another 
was first accomplished in 1954, when a kidney was trans- 
planted. Now, more than 4,000 kidney transplants are per- 
formed annually in the United States. During the past two 
years, A Matter of Life Consortium, in collaboration with the 
Department of Environment, Health and Natural Resources 
Organ and Tissue Advisory Committee, have made a con- 
certed effort to increase organ and tissue donations by work- 
ing with the Division of Motor Vehicles, the North Carolina 
Medical Society, the North Carolina Hospital Association, 
and other interested parties, to educate the public to the need 
for organs and tissues. 

Subcommittees of these programs have worked toward 
developing awareness programs through the state's public 
health education system. They have worked with hospital 
administrators and medical staff to increase their awareness 
of needs, and educated the public about the benefits, of 
transplantation. A minority education subcommittee has 
been working with select populations to increase their aware- 
ness of need and proclaim the benefits of transplantation. 

The Department of Environment, Health and Natural 
Resources, the organ procurement agencies, the North Caro- 
lina Hospital Association, the North Carolina Medical Soci- 
ety, and the North Carolina Neurological Society have joined 
together in a memorandum of understanding. Their goal is to 
encourage hospitals, organ procurement organizations, and 
physicians to collaborate as a team to ensure that all families 
of potential organ and tissue donors have the opportunity to 
make informed decisions regarding organ/tissue donation. 

□ 



It's A Matter of Life 

One of modern medicine's greatest achievements is the transplanta- 
tion of organs and tissues. For the thousands of Americans who have 
been stricken with end-stage organ failure, transplantation offers a 
second chance at life. 

A critical shortage of donated organs and tissues exists; however, 
more than 26,000 Americans currently await a transplant including 
more than 700 North Carolinians. Every 30 minutes, another name 
is added to the list. 

Because none of us can predict the future, now is the best time to 
make your decision about donation. Lifesaving transplants cannot 
happen without organ and tissue donors-people like you who choose 
to give the gift of life to others. It is also important to discuss donation 
with your family. Sharing your decision now allows your family to 
fulfill your wishes. 

You can make a difference in the lives of others. Please fill out and 
sign the attached donor card. Carry it with you at all times, and keep 
it with your driver's license. Organ and tissue donations truly is a 
matter of life. 

How to Become an Organ Donor 

1 . Complete the Uniform Donor Card below and carry it with you 
at all times. 

2. You will be asked by the license examiner if you are an organ 
donor. If you answer "yes," this will be indicated on your 
driver's license. 

3. If you are less than 18 years old, you can be an organ donor 
with your parent's permission. 



Organ Donor Card 



Print or Type Name of Donor 

In the hope that I may help others, I hereby make this anatomical gift 
to take effect upon my death. The words and marks below indicate 
my desires. 



I give: 



(a)_ 
(b)_ 



any needed organs and tissues 
only the following organs or tissues: 



specify the organ(s) or tissue(s) for the purpose of transplantation, 
therapy, medical research or education. Limitations or special 
wishes, if any: 



Please detach and give this portion to your next-of-kin-. 

This is to inform you that I want to be an organ and/or tissue donor 
should the occasion ever arise. Please see that my wishes are carried 
out by informing attending medical personnel. 



Signature Date 

NCMJ May/ June 1 996, Volume 57, Number 3 1 55 



Questions and Answers about 
Organ and Tissue Donation 



Will there ever be a choice between saving my life and using my 
organs and tissues for transplantation? No. Organ and tissue 
donation can only occur after all efforts to save your life tiave been 
exhausted and deatti has been legally declared by a licensed physi- 
cian. 

Who will receive my organs and tissues? They will be transplanted 
into those people who need them most urgently based on medical 
criteria, blood type and geographical location. 



Is there any cost involved should I decide to become an organ and 
tissue donor? No. There isabsolutelynocosttoyourestateortoyour 
family. 

Will organ and tissue donation affect funeral arrangements? Re- 
moval of organs and tissues will not interfere with customary funeral 
arrangements or traditional viewing services. 

What organs and tissues can be transplanted? There are many 
including heart, kidneys, liver, lungs, pancreas, skin, bone and eyes. 
You may specify any or all that you wish to donate. 



If you wish to leave your body for medical research or education 
contact a school of medicine or call (919) 733-7081. 



The following must be signed by the donor in the presence of the 
witnesses who sign in the presence of the donor. 



Signature of Donor 



City & State 



Date Signed 



Phone Number of Donor 



Social Security No. of Donor 



Witness 



Witness 



THIS IS A LEGAL DOCUMENT UNDER THE UNIFORM ANATOMICAL 
GIF ACT (CHAPTER 130A, ARTICLE 16, PART 3 OF THE NORTH 
CAROLINA GENERAL STATUTES.) 



Most Frequently Transplanted 
Organs and Tissues 



Tissues: 
Corneas (2) 

Organs: 

Lungs (2) 
Heart (1) 
Liver (1) 
Pancreas (1) 
Kidneys (2) 




156 



NCMJ May/ June 1996, Volume 57, Number 3 




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THE SPECTRUM OF DISEASE 



Alzheimer's Disease Then and Now 

Can We Really Explain the Disparity in Prevalence? 

John M. Lewis, MD 



Alzheimer's disease is a common tragedy afflicting millions of 
people in this country alone.' S ince dreadful diseases often have 
fascinating stories behind them, I decided to look at Alzheimer's 
disease from a historical perspective, using a variety of literary, 
medical, and historical sources. I expected to find a wealth of 
information about a disease as prevalent as Alzheimer's now is. 
I was, therefore, surprised to learn that this disease was not even 
officially named until 1907. Even more surprising was the 
claim of Dr. Alois Alzheimer himself, who asserted then that 
the disease was new to medical science.^ 

In fact, Alzheimer's case was not new, but had been known 
by a variety of names in previous centuries, and was thought to 
be related to old age. An accurate description is found in 
Gulliver s Travels, published in 1 727, and there is evidence that 
its famous author, Jonathan Swift, died with the disease.' 
Descriptions also appear in two neurological classics published 
around 1800, Philippe Pinel's A Treatise on Insanity and 
Benjamin Rush's Medical Inquiries and Observations on Dis- 
eases of the Mind. At that time it was called "dementia" or 
"fatuity of old age," and both Pinel and Rush described it briefly 
as an incurable affliction, strongly linked to aging."-* By 1850 
the disease was being called "senile dementia" and detailed 
case reports (some including pathological data) began to emerge, 
documenting its occurrence years before Alzheimer's report.' 
However, while these references document existence of the 
disease before the 20th century, I find little to indicate that it was 
common. 

Less than 90 years after first being named, Alzheimer's 
disease is so prevalent that it threatens to overwhelm the public 
and private health resources of this country. The financial 
burden of the disease is enormous, and the psychological price 
paid by victims and families is incalculable. How can it be that 
a disease so uncommon at the beginning of the century has made 
such strides by the end of the same century? Two explanations 
are conventionally offered: 



Dr. Lewis resides at 8220 Whitewater Drive, Clemmons 2701 2. 



1) Dr. Alzheimer originally described a dementia with 
onset at an early age. For many years thereafter the diagnosis of 
Alzheimer's disease was reserved for a rather rare type oi pre- 
senile dementia. The age criterion was only fairly recently 
dropped, when it became apparent that Alzheimer's dementia 
is a single disease process, regardless of age of onset.' Naturally 
enough, abolishing the age criterion has increased the number 
of patients labeled as having "Alzheimer's disease" rather than 
cerebral arteriosclerosis or organic brain syndrome. 

2) Since Alzheimer's is primarily a disease of old age, and 
the size of the elderly population is increasing rapidly,' its 
prevalence has increased. Statistically, about 10% of Ameri- 
cans above the age of 64 have the disease.' According to the 
1990 US census, there were 3 1 million Americans over 64,' of 
whom over three million were afflicted, accounting for the 
majority of Americans then believed to have the disease.' 

The argument based on an aging population seems plau- 
sible, until we look at the figures from the 1890 US census. At 
that time, the population of this country was nearly 63 million, 
and 2.4 million were 65 or older.' Ifaging itself were the chief 
risk factor,' then we would predict 240,000 cases of Alzheimer's 
disease (or "senile dementia") in 1890. Where was this virtual 
army of victims? Surely a disease with such bizarre symptoms, 
and in such significant numbers, would not have escaped 
attention in 1890. Yet I can find no convincing data to support 
the prediction. 

Indeed, fragmentary and anecdotal evidence points to 
exactly the opposite conclusion. For example, of 754 patients 
admitted to the Virginia State Asylum for the Insane in 
Williamsburg from 1868 to 1879, old age was cited as the cause 
for insanity in exactly one case.' The diagnosis of mental 
disease was an imprecise art then, as now, but our medical 
predecessors were well aware of the link between old age and 
dementia and managed to record but a single case over 1 1 years 
at a state mental hospital! 

Mental illness was by no means rare in the US in 1890. 
According to the 1890 census, 202,094 Americans were deemed 
insane or mentally feeble.'" Some of these cases would have 



158 



NCMJ May/June 1996, Volume 57 Number 3 



been caused by diseases rarely seen today, such as neurosyphilis, 
but the total number is still significantly less than would have 
been expected from Alzheimer's disease alone. 

The year 1890 happened to be remarkable for one very 
important event in American medicine: William Osier began 
work on his monumental Principles and Practice of Medicine, 
published in 1892. In his extensive section on neurological 
disease, Osier records nothing remotely resembling what we 
now know as Alzheimer's disease." Had this distinctive di.sease 
existed in large numbers at the lime, is it likely that the great 
Osier would have missed it? 

Clearly, Alzheimer's disease existed long before it re- 
ceived its current name, but I contend that it was fairly uncom- 
mon, even as late as 1890. That era antedated the original and 
the revised criteria for diagnosing Alzheimer's disease, thereby 
weakening the first of the conventional explanations for the 
increased prevalence of the disease. And the second explana- 



tion, the demographic argument, cannot account for the appar- 
ently sudden and significant rise in prevalence between 1890 
and 1990. 1 believe that the perceived surge in prevalence is real, 
not merely a phenomenon of semantics and demographics. 1 
suspect that the substantial change in prevalence reflects an 
accompanying change in the causative basis of Alzheimer's 
disease, and that this in turn favors an environmental etiology 
for the disorder. 

It is curious, perhaps telling, that authorities occasionally 
use the word "epidemic" to describe Alzheimer's disease.'^" In 
its classical application, "epidemic" refers to diseases caused 
by infection or toxins. Since Alzheimer's disease is currently 
thought not to be infectious,'" and if it w an epidemic, then could 
the disease have a toxic etiology? The history of the disease 
suggests this to me, and I do not think that this possibility should 
be discounted until proven otherwise. □ 



References 

1 Evans DA, Scherr PA, Cook, NR, et a]. Estimated prevalence of 
Alzheimer's disease in the United Stales. The Millbank Quarterly 
1990;68:267-89, 

2 Alzheimer A. Ober eine eigenartige Erkiankung der Himrinde. 
Centralblatt fiir Nervenheilkundc und Psychiatric 1907;March 
1:177-9. 

3 Lewis JM. Jonathan Swift and Alzheimer's disease. Lancet 
1993;342:504. 

4 Pinel P. A Treatise on Insanity (trans. DD Davis, facsimile reprint 
ofa translation of the 1801 edition). New York: Hafner Publishing 
Co., 1962, pp 200-1. 

5 Rush B. Medical Inquiries and Observations on Diseases of the 
Mind (facsimile of the Philadelphia 1812 edition). New York: 
Hafner Publishing Co., 1962, pp 294-6. 

6 Berrios GE. Alzheimer's disease: a conceptual history. Inll J Ger 
Psych 1990;5:355-65. 

7 StatisticalAbstractof the UnitedStates 1992, 1 12th ed. Washing- 
ton, DC: US Bureau of the Census, 1992, p 14. 

8 Abstract of the Eleventh Census: 1890. Second edition, revised 



and enlarged. Washington, DC: Government Printing Office, p 60. 
9 Zwelling S. Quest for a Cure. Williamsburg, VA: The Colonial 
Williamsburg Foundation, 1985, p 56. 

10 Abstract of the Eleventh Census: 1890. Second edition, revised 
and enlarged. Washington, DC: Government Printing Office, p 
276. 

1 1 Osier W. The Principles and Practice of Medicine. New York: D. 
Appleton and Co., 1892, pp 775-994. 

1 2 Plum F. Dementia: an approaching epidemic. Nature 1 979;279:372- 
3. 

1 3 Smith C, Anderton BH. The molecular pathology of Alzheimer's 
disease: are we any closer to understanding the neurodegenerative 
process? Neuropathol Appl Neurobiol 1994;20:322-38. 

14 Beal MF, Richardson EP, Martin JB. Degenerative diseases of the 
nervous system. In: Wilson JD et al, eds. Harrison's Principles of 
Internal Medicine, 12th ed. New York: McGraw-Hill, Inc., 1991, 
p 2062. 



Commentary 

Albert Heyman, MD, and Florence Nash, MA 

Dr. Lewis has written an interesting, provocative article on the 
apparently "sudden appearance" of Alzheimer's disease 
(AD) during the past few decades. In support of hiis point that 
the frequency of AD is rapidly increasing, Dr. Lewis cites a 
recent estimate that 1 0% of Americans over age 64 may have 
this disease (a population survey from East Boston found a 
prevalence of 10.3%'). However, many researchers in the 
field think that this estimate is high. Most surveys of dementia 
in various populations indicate that about 5%-7% persons 
over age 65 have clinical dementia.^ The reason for the 
discrepancy is not apparent. 

Based on the 1 890 US census, if the prevalence of AD 
were 1 0%, then perhaps a quarter of a million persons would 



have been suffering from this disorder at the turn of century, 
so it is surprising that it was not commonly mentioned in 
medical texts. As Dr. Lewis points out, the first edition of 
Osier's Principles and Practice of Medicineconta'ms no entry 
on "senile dementia." Perusal of the second edition (1897) 
also fails to find mention of senile dementia or that caused by 
cerebrovascular disease.^ We speculate that Osier failed to 
comment on dementia because of the perception at the time 
that progressive loss of memory and orientation in the elderly 
was not a disease but simply a manifestation of normal aging. 
When Alois Alzheimer called attention to this disorder in 
1 907," he described an institutionalized, severely demented 
woman who was only 51 years old. He based the diagnosis 



NCMJ May /June 1996, Volume 57 Number 3 



159 



primarily on neuropathological findings, which had been 
previously overlooked partly because of the lack of sensitive 
silver stains to detect neurofibrillary tangles and amyloid 
plaques. 

The fact that so few cases of senile dementia were 
reported among the population of the Virginia State Asylum 
for the Insane may well be because such institutions existed 
primarily to isolate and restrain persons whose behavior was 
potentially dangerous to society or themselves. Persons with 
"senile dementia" would not usually have posed a danger, 
and families unable to care for them may well have sent them 
to then-common old-age homes or "rest homes" rather than 
insane asylums. 

We agree with Dr. Lewis that the word "epidemic" is 
inappropriately applied to Alzheimer's disease. Publications 
that referred to Alzheimer's disease as a "silent epidemic"did 
so primarily to draw the attention of the medical profession to 
this problem. Certainly it was effective, if not accurate. 



As for the etiology of this disease, a growing body of 
research indicates, at least in affected younger persons, a 
genetic disturbance of various chemical processes, which 
leads to formation of plaques and tangles in the brain and 
consequent destruction of neurons. In a way, this disturbance 
might be called "toxic," although not in the sense of causation 
by any external or environmental toxins. Other recent find- 
ings, such as the association between AD and apolipoprotein 
E, suggest that, in older persons with AD, the underlying 
factors may be different. Clearly, much remains to be deter- 
mined about the nature and causes of this disorder. □ 



Dr. Hey man is Professor Emeritus, Department of Medicine, 
Dulie University Medical Center, Durliam 27710, and Princi- 
pal Investigator, Consortium to Establish a Registry for 
Alzheimer's Disease. Ms. Nash is Research Analyst, Consor- 
tium to Establish a Registry for Alzheimer's Disease. 



References 

1 Evans D, Scherr, PA, Cook NR, et al. Estlimated prevalence of 
Alzheimer's disease in the United States. The Millbank Quarterly 
1990;68:267-89. 

2 Breteler MMB, Claus JJ, van Duijn C, et al. Epidemiology of 
Alzheimer's disease. Epid Rev 1992;14:59-82. 

3 Osier W. The Principles and Practice of Medicine, 2nd ed. New 



York: D. Appleton and Co., 1897. 
4 Alzheimer A. A characteristic disease of the cerebral cortex. 
Allgemeine zeitschrift fur psychiatrie und psychisch-gerichtliche 
medizin 1907;64:146-8. Reprinted in Bick et al, eds. The early 
story of Alzheimer's disease. Padua, Italy: LJviana Press, 1987. 



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TOXIC ENCOUNTERS 



"Macbeth Does Murder Sleep" 

The Mysterious Mythic Melatonin Morass 

Ronald B. Mack, MD 



Macbeth was a terrible wuss. He wanted to be King of Scotland 
but could not find within himself the courage to kill the reigning 
king.' Lady Macbeth goaded and belittled him to commit the 
foul deed, which he finally accomplished. Poor wimp, in those 
days of no Berettas or AK 47s he had to off the sleeping king 
with adagger. Afterward, his superego worked its worst on him. 
He could not sleep. He cried out "Macbeth does murder sleep, 
the innocent sleep, sleep that knits up the ravell'd sleave of care, 
the death of each day's life,... balm of hurt minds...."' Our 
reluctant regicide could have used a king-sized dose of melato- 
nin but the local Eckerd's drugstore was closed. 



Get Real, Pineal! 

In 1958, Dr. Aaron Lemer, an American dermatologist, isolated 
from beef pineal glands the most potent amphibian skin- 
lightening factor then known.^ Can you imagine saying to your 
dean or division chief: "I need some big money to harvest pineal 
glands from cows so I can isolate a chemical that causes 
amphibians to look more attractive?" In most centers of higher 
learning you would be whisked away in a trice, placed in a 
rubber room, and given an intravenous drip of a potent phe- 
nothiazine. But Dr. Lemer got lucky and found the compound 
named N-acetyl-5-methoxytryptamine (which he called mela- 
tonin because of its ability to cause pigment contraction of 
amphibian melanophores). 

Speaking only for myself, I don't remember much about 
the pineal gland, do you? I was in medical school so long ago 
that to study gross anatomy we had to steal the corpses left 
behind by the "gang wars" that occurred in our neighborhood. 
We were careful to choose the cadavers with the fewest Tommy- 



Dr. Mack is Associate Professor, Department of Pediatrics, 
Bowman Gray School of Medicine, Medical Center Boulevard, 
Winston-Salem 27157. 



gun wounds, so as to make dissection easier. Today, my 
younger colleagues tell me that the pineal body is a small 
glandular structure that lies between the superior coUiculi of the 
brain.' It is shaped like a miniature pine comb — hence "pi- 
neal" — and attached by a stalk to the posterior region of the 
third ventricle. It usually calcifies in middle age after which it 
may be readily visualized on x-ray. The pineal is small (50 mg- 
1 50 mg in humans), but has a rate of blood flow second only to 
the kidney.^ It is composed of pincalocytes (modified photore- 
ceptor cells) and glial cells. You may remember, from some- 
where in the dim past, reading about our "third eye"; that title 
referred to the pineal body. 

The function of the pineal differs in different fauna, but it 
has an entirely a secretory function in mammals. Melatonin 
production in the pineal is conu^oUed by sympathetic alpha-1 
and beta-1 receptors in the gland."* The pineal endocrine cells 
(the pincalocytes) receive sympathetic nerve endings that re- 
lease the neurotransmitter noradrenaline during darkness. Act- 
ing on the beta adrenergic receptors, noradrenaline induces the 
uptake of tryptophan and its transformation into melatonin via 
a precursor, serotonin. 

Melatonin is metabolized in the liver, and more than 85% 
of an administered dose is excreted in the urine as 6- 
sulphatoxymelatonin, measurement of which provides a reli- 
able index of endogenous melatonin production.'' The plasma 
half-life of melatonin is short, 20-50 minutes. Five milligrams 
of melatonin given by mouth produces a peak blood level that 
is 25-fold higher than physiologic levels without altering en- 
dogenous melatonin production. In the pineal tryptophan is 
hydroxylated and decarboxylated to serotonin (5-hydrox- 
ytryptamine). The enzyme serotonin N-acetyltransferase then 
catalyzes the N-acetylation of serotonin, and is probably the 
rate-limiting step in melatonin synthesis. Who cares, you ex- 
claim? You'd better care because many of your patients are 
taking this stuff. They buy it in health food stores, often after 
reading one of the many books available to the lay public like 
the popular. Melatonin Miracle. Melatonin is now sometimes 
called "nature's sleeping pill." 



162 



NCMJ May/June 1996, Volume 57 Number 3 



Chronobiology and Melatonin 

What makes this chemical so intriguing, you ask? Let us go 
back to its physiology. Serotonin N-acctyltransferasc activity 
increases 30-70 fold in the pineal during the dark phase of the 
24-hour cycle. As a result, under normal conditions melatonin 
production occurs exclusively at night,'' and the synthesis of 
melatonin at night is the sole known physiological role of the 
pineal. Melatonin synthesis also occurs in the retina and is also 
conu-olled by the light-dark cycle.^'^ The retina relays light 
perception by way of a multisynaptic neural pathway to the 
suprachiasmatic nucleus of the hypothalamus, from whence it 
ultimately regulates the pineal gland. Melatonin secretion usu- 
ally begins at 9 p.m. and peaks between 2 a.m. and 4 a.m. 
Nocturnal levels are highest in children and decrease with age. 

Melatonin plays a major role in regulating sleep, in syn- 
chronizing circadian rhythms, in pubertal development, and in 
the functioning of the neuroendocrine reproductive axis.' It is 
part of our biological clocks, the timing mechanisms present in 
living organisms that control the rhythm of functions and 
processes. These clocks keep the activities of living things in 
harmony with temporal changes in the environment. In human 
type people, like us, biological clocks set periods of sleep and 
wakefulness and of many body activities. Maybe these clocks 
should be made part of Galen's theory that the body's four 
"humours" had to be in balance for a person to be considered 
healthy. 

Biological rhythms based on a day-night cycle are called 
circadian rhythms (from the Latin circa dies — "about a day").' 
For most living things, except possibly busy medical practitio- 
ners, the day-night cycle is divided into periods of activity and 
periods at rest. These periods do not occur at the same time for 
all living organisms. Most of us are most active during the day 
and attempt to rest at night; on the other hand, bats, cats, moths, 
owls, rats, obstetricians, many pediatricians, and criminals are 
more active at night. 

Our biological clocks operate on schedules that seem to 
promote health, and in us human types there are daily, weekly, 
monthly, and even seasonal rhythms. Apparendy most vital life 
processes have circadian rhythms. Our hormones and various 
other chemicals in the bloodstream vary, at times dramatically, 
throughout various time periods. Melatonin helps coordinate 
the activities of cells, glands, and organs with each other and 
with the day-night rhythm of the environment. Jet lag is a good 
example of the adverse consequences of tampering with our 
internal rhythm system. And a recent article' suggested that, if 
you feel persistenUy tired day after day, you might try dimming 
the lights a few hours before bedtime. The idea is that exposure 
to normal indoor lighting prompts the body to stay awake past 
midnight and not get sleepy until approximately 5 a.m. Is this 
theory for the birds, literally and figuratively? 

Think for a moment about the diseases that seem to follow 
biological rhythms: cerebral hemorrhages are more common in 
the late evening; a large percentage of heart attacks occur in the 
morning; asthmatics are often worse in the evening and over- 



night. At this point the reader might ask what all this stuff has 
to do with melatonin? The current fascination with melatonin in 
our culture relates to the science (at least I hope it is science) of 
chronobiology and its daughterdisciplines — chronopathology, 
chronopharmacology, even chronobiolics' — and melatonin's 
role in circadian and seasonal rhythms. In all vertebrates, 
whether nocturnal or diurnal, melatonin levels are low during 
the day and high at night. This diurnal cycle tells systems 
throughout the body whether it is day or night. Furthermore, by 
"sensing" the length of high melatonin levels, subhuman verte- 
brates can "know" the relative length of night and day, and thus 
the season of the year. Of course, my father would have said "A 
more efficient way to do this is to look out the window." 



Melatonin — Radical Wonderworker? 

Alas, melatonin levels decrease markedly with age. This has led 
many authors to hypothesize that the decline is partially a 
response to the aging process and age-related disease. Hence, 
melatonin is touted as a way of prolonging life, improving 
health, and having more and better "slap and tickle." One of the 
current reasons offered by some to explain ill health — cancer, 
cardiovascular disease, old-age related infirmities, etc. — is the 
presence of free radicals.* Free radicals are atoms or molecules 
that lack one or more electrons. This makes them unstable, 
prone to latch on to other compounds, to disrupt structure and 
function. If the number of free radicals is high enough, cells can 
die or at least be permanently damaged. Megadoses of certain 
vitamins are alleged to free us from such "radical" ravages. If 
you believe in this theory, you probably believe that the deterio- 
ration of cells and tissues we call "aging" is caused by these 
"bad boys." You probably also believe that free radicals con- 
tribute to the formation of arterial plaques, and other unpleasant 
scenarios. The damage caused to cells by free radicals is due to 
oxidation. Certain substances, such as beta carotene, melatonin, 
linguine alia vongole (just kidding), are considered antioxi- 
dants and, therefore, might prevent or ameliorate free-radical 
damage. One very current book for the lay audience maintains 
that melatonin is the most efficient free-radical scavenger ever 
discovered.' 

I should mention at this juncture that melatonin is generally 
considered to be non-toxic* Most studies report no clinical 
adversities from its use. Some references do mention minor 
annoyances such as headache and transitory depression, even 
with low doses.'" Melatonin has not yet been approved for sale 
as a drug product, but it is currently commercially available (in 
your local health food store, for example) as a nutritional 
supplement. The present products are either derived from 
animal pineals or are synthetic. Do not be foolish enough to 
purchase the non-synthetic form — you do not need to run even 
the theoretical risk of viral transmission or contamination. 
Current commercial tablets are available in 3 |a.g, 1.5 mg, or 3 
mg sizes." Time will tell if melatonin has any real value; no 
studies of long-term use are available, but should be performed. 



NCMJ May/June J 996, Volume 57 Number 3 1 63 



Smoke — But Little Light 

Well if ingesting melatonin for whatever reason probably will 
not hurt you, is there any scientific evidence that it can help you 
achieve restful sleep, avoid jet lag, 1 i ve longer and heal ihier, and 
be more fulfilled sexually? The subject of melatonin has pro- 
duced a lot of noise but not much music. Much of what has been 
written in the lay press presents hypotheses as if they were solid 
facts. Unfortunately, few solid scientific data are available to 
the consumer, despite the witch's brew of pseudo-information 
thrust on a gullible public. We need real clinical research and 
large-scale clinical trials. The FDA does not at present regulate 
the sale of melatonin, but maybe it should. 

What do we know? It appears that low doses of melatonin 
can promote sleep onset in patients who have trouble getting to 
sleep, but these same low doses may not maintain sleep. A 
sustained release preparation may be better for this. Very large 
doses, given at bedtime, have produced significant hypnotic 
results, but in the studies involving only a small number of 
patients. Some data, again from small-size studies, suggest that 
melatonin can ameliorate "jet lag" by generally improving 
daytime fatigue, disturbed sleep cycles, mood, and recovery 



times. All of the conclusions have been based on subjective 
endpoints rather than objective data such as blood Cortisol 
levels. 



Double, Double, Toil and Trouble 

Poor Lady Macbeth! She thought she was so "macho." When 
she developed her plan to unseat the king, she said to herself: 
"Come, you spirits that tend on mortal thoughts, unsex me here, 
and fill me, from crown to the toe, top-full of direct cruelty!" 
After her participation in the foul deeds she got a bad case of 
somnambulism and a hand-washing fetish. She had horrible 
nightmares in which she could not wash the blood from her 
hands, moaning "Out, damned spot! Out, I say!" and "What, 
will these hands never be clean?" and "Quick! fetch me the 
melatonin!" ' 

The Lady Macbeth, at last the queen, died. Macbeth, 
distraught, murmured "Life's but a walking shadow, a poor 
player that struts and frets his hour upon the stage, and then is 
heard no more. It is a tale told by an idiot, full of sound and fury, 
signifying nothing."" □ 



Author's dedication: I would like to dedicate this article in 
memory of Dr. Jay Arena, a friend and hero who passed away 
in January. He was a role model for me as I'm sure he was for 
an untold number of students, house staff, and colleagues. In all 
honesty he was the most humble and unassuming doctor I ever 
met. He had accomplished much in his long life, but when you 



had breakfast or lunch with him he wanted to hear about your 
work, your life, your accomplishments. Jay Arena was a gentle- 
man with a remarkable work ethic who worked until the day 
before he died; he was 86. Unfortunately we are not likely to 
experience his kind of human being again in our lifetime. He 
made a difference in the lives of children — gosh, /' // miss him. 



References 

1 Asimov I. Asimov'sGuidc to Shakespeare, Vol. 2, Macbeth. New 
York: Avenal Books, 1970. pp 149-203. 

2 Arcndt J. Melatonin. Clin Endocrinology 1988;29:205-29. 

3 Sncll RS. Clinical Anatomy for Medical Students. Boston: Little 
Brown and Co., 1973, p 708. 

4 Melatonin. The Lawrence Review of Natural Products, January 
1996, pp 1-5. 

5 Generali JA. Melatonin. Drug Newsletter 1996;15:3-5. 

6 Biological clock. World Book Encyclopedia, Vol. 2. Chicago: 
World Book, Inc., 1992, pp 314-5. 



7 Health report. Time Magazine Feb. 19, 1996, p 19. 

8 Turek FW. Melatonin hype is hard to swallow. Nature 
1996;379:295-6. 

9 Bock SJ, Boyette M. Stay Young the Melatonin Way. New York: 
Penguin Books USA, Inc., 1995. 

1 Petrie K, Dawson AG, Thompson L, Brook R. A double-blind trial 
of melatonin as a treatment for jet lag in international cabin crews. 
Biol Psychiatry 1993;33:526-30. 

1 1 Waiih EM, ed. The Tragedy of Macbeth. New Havea CT: Yale 
University Press, 1954, pp 86, 95. 



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164 



NCMJ May I June 1996, Volume 57 Number 3 




An OPERAnoN 

That'u Make 

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CME Calendar 



May? 

Symposium on Inrectious Diseases 

Place: NC Biotechnology Center, Research Triangle Park 

Fee: $65 

Info: Joni Tanner, Continuing and Professional Education, 

NC State University, Box 7401 , Raleigh 27695-7401, 

919/515-8171, fax: 919/515-7614 

May 15-17 

Carolinas Medical Center Symposium 

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up to 24 hours Category 1 , AM A 
MD/PhD/DDS/DMD: $150 full conference, 
$100 single day; RN/RPh/allied and public health: 
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Mary Anne Cox , CME Coordinator, CMH A Office of 
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May 29-June 1 

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May 30 

NC Association for Biomedical Research Annual Meeting 

Place: NC Biotechnology Center, Research Triangle Park 
Info: NCABR, P.O. Box 25459, Raleigh 2761 1-5459, 
919/829-3911, fax: 919/829-3912 

May 30-31 (and October 31 -November 1) 
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Fee: $150 

Info: Iris Ahlheit, RN, Course Coordinator, Rex Healthcare, 

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May 31 

American Medical Writers Association Workshops: 
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Fees: AMWA members: $70/session, $130 for 2; 

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May 31-June 1 

Current Therapy in Venous Disease 

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Credit approx. 10 hours Category 1, AMA 

Fee: $175 

Info: Regisu-ar, UNC Office of CME, CB# 7000, 23 1 
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June 1 

Writing for Publication: 

A Workshop for Biomedical Professionals 

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Fee: $40 (includes lunch) 

Info: Biomedical Editors, 2216 W. Club Blvd., Durham 

27705,919/493-7583,e-mail: bioedit@ix.netcom.com 

(see ad, pg. 171) 

June 6-9 

Comprehensive Internal Medicine Board Review Course 

Place: Hawthorne Inn, Winston-Salem 

Credit: 28.5 hours Category 1, AMA 

Fee: MDs: $495, PAs and residents: $275 

Info: Division of CME, Bowman Gray School of Medicine, 

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June 11-15 

5th Annual Advanced Coronary 

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Credit: 1 8 hours Category 1 , AMA 

Fee: $695 

Info: Mary Anne Cox, CME Coordinator, CMHA Office of 

CME, 1366 E. Morehead St., Charlotte 28204, 

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June 21 

NC Society of Addiction Medicine Seminar: 

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919/990-9559, fax: 919/990-9518 (see ad, pg. 179) 



168 



NCMJ May/June 1996, Volume 57 Number 3 



June 21 

UNC Ophthalmology Residents' Day 

Place: UNC-Chapcl Hill 

Info: Christine C. Cotton, UNC Dcpt. of Ophthalmology, 

CB# 7040, 617 Bumclt-Womack Bldg., Chapel Hill 

27599,919/966-5296 

July 5-7 

26th Annual Sports Medicine Symposium 

Place: Shell Island Resort, Wrightsville Beach 
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800/722-1350 (in NC), 919/833-3836 

July 29-August 2 

25th Annual Emery Miller Medical Symposium 

Place: Myrtle Beach, SC 

Credit: 20 hours Category 1, AMA 

Info: Division of CME, Bowman Gray School of Medicine, 

910/716-4450 or Physician Access Line, 

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August 2 

Workshop on Domestic Violence Prevention 

Place: Charleston, SC 

Info: hosted by the National Coalition Against Domestic 
Violence; for info call Lisa Jemigan, NC Medical 
Society, 800/722-1350 (in NC), 919/833-3836 

August 6-8 

4th Annual Conference on Hazardous 

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Fee: SI 25 

Info: Joni Tanner, Continuing and Professional Education, 

NC State University, Box 7401 , Raleigh 27695-7401, 

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September 17-21 

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October 11-12 

20th Annual Frank R. Lock Ob-Gyn Symposium 

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Info: Division of CME, Bowman Gray School of Medicine, 

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October 12-13 

23rd Alexander Spock Lung and Gut Symposium: 
Outpatient Management of Lung and Gut 
Problems in Pediatric Patients 

Place: Searle Center, Duke University Medical Center 
hours pending 

MDs: $150 both days, $75 half day; allied health 
professionals: $90; MDs in training: no charge 
(with letter from training director) 
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Professor of Pediatrics, Box 2994, DUMC, Durham 
27710, 919/684-2289, fax: 919/684-2292 



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October 25-27 

17th Mountain Medical Meeting 

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NCMJ May/June 1996, Volume 57 Number 3 1 69 



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170 



NCMJ May/June 1996, Volume 57 Number 3 



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CLINICAL PRACTICE 



Biologic Hazards of Double Primary 
Neoplasms Among Patients with 
Genitourinary Malignancy 

J. Brantley Thrasher, MD, Richard K. Dodge, MS, Judith E. Robertson, CTR, and David F. Paulson, MD 



Billroth first described multiple malig- 
nancies arising in one or more organs in 
1889.' In 1932, Warren and Gates' gave 
criteria for diagnosing multiple primary 
malignancies: 1) each tumor must present 
a definite picture of malignancy; 2) each 
must be distinct; and 3) the possibility 
that one is a metastasis of the other must 
be excluded. Now, the occurrence of 
multiple primary neoplasms is well es- 
tablished, rather than being merely a 
medical curiosity. 

The incidence of multiple primary 
neoplasms varies in published reports 
from 2.8% to 36%.''' The different rates 
found in different series reflect variation 
in the duration of patient follow-up, the 
use of autopsy data in some but not all 
studies, the study of only synchronous 



Dr. Thrasher is Residency Program Di- 
rector, Department of Urology, Depart- 
ment of the Army, Madigan Army Medical 
Center, Tacoma WA 98431-5000. This 
study was performed while Dr. Thrasher 
was a fellow in Urologic Oncology, funded 
by the US Army, at Duke University Medi- 
cal Center, Durham. Mr. Dodge is a mem- 
beroftheDepartmentof BiostatisticsjMs. 
Robertson works in Computing and Data 
Management; and Dr. Paulson is Profes- 
sor and Chair, Division of Urology, De- 
partment of Surgery, Duke University 
Medical Center. The opinions herein rep- 
resent the authors' and do not necessarily 
reflect those of the Department of De- 
fense or the US Army. 



(two tumors discovered within 6-12 
months of each other) or of both synchro- 
nous and metachronous (a second tumor 
discovered more than 1 2 months after the 
original one) tumors, and the inclusion or 
exclusion ofmultiple primary neoplasms 
of mullicenu^ic origin. 

Most studies ofmultiple primary neo- 
plasms have investigated the relative in- 
cidence of multiple primaries and the 
possible explanations of the phenom- 
enon.'^'' Few have considered the rela- 
tive biologic hazards produced by mul- 
tiple primaries arising in different organs 
and tissues. At present, because advanced 
radiologic staging methods are used in 
the preoperative assessment of cancer 
patients, second primary neoplasms will 
almost certainly be found more com- 
monly. We undertook the present study 
to determine the adverse impact of a 
second primary in patients with a first 
malignancy in the genitourinary system. 
We wanted to know whether the first or 
second tumor represented the greatest 
hazard to the patient, and whether pa- 
tients who had two primary malignancies 
of the genitourinary system had risks 
equivalent to those whose second cancer 
was not of genitourinary origin. To ad- 
dress these questions, we reviewed the 
clinical course of 158 patients who pre- 
sented with a genitourinary first malig- 
nancy and a synchronousor metachronous 
second primary malignancy. 



Materials and Methods 

Patients. Between January 1, 1975, and 
December 31, 1984, 204 patients who 
had been treated at Duke University Com- 
prehensive Cancer Center for a genitouri- 
nary malignancy were subsequently found 
to have a synchronous or metachronous 
second primary malignancy. Forty-six of 
the 204 were excluded because of incom- 
plete records (in 29 cases), or diffuse 
metastatic disease at presentation (16 
cases), or the absence of pathologic con- 
firmation of a second cancer (one case). 
The remaining 158 patients form the ba- 
sis of this report. 

We documented the occurrence of 
multiple primaries by reviewing patient 
data from the Duke University Cancer 
Center Database and the patients' medi- 
cal records. We used the inclusion crite- 
ria of Warren and Gates' to diagnose 
multiple primary tumors. For all patients 
included in the study, a pathologic diag- 
nosis was established for both malignan- 
cies by percutaneous needle or incisional 
biopsy, surgical resection, or endoscopic 
brushings. 

Tumors were staged using the tu- 
mor/node/metastasis (TNM) system or 
staged clinically when it was impossible 
to determine the pathologic stage. TNM 
classifications werenot used for hematog- 
enous malignancies; five patients had non- 
Hodgkin's lymphoma staged using the 



172 



NCMJ May /June 1996. Volume 57 Number 3 



Ann Arbor staging system. A 
histopathological grade (well, moder- 
ately, or poorly differentiated) was as- 
signed wherever possible. 

We divided our patients into two 
groups: Group 1 presented with a geni- 
tourinary neoplasm and acquired a sec- 
ond primary urologic neoplasm (pros- 
tate, bladder, or kidney cancer); Group 2 
presented with a genitourinary neoplasm 
but acquired a nonurologic second pri- 
mary (lung, gastrointestinal, or hematog- 
enous cancer). 

All patients received conventional 
therapy. Genitourinary and gastrointesti- 
nal neoplasms were surgically resected if 
they were organ-confined. Head and neck 
neoplasms were surgically resected and 
radiation therapy added in select cases. 
Lung neoplasms were treated with radia- 
tion therapy, surgical resection, chemo- 
therapy, or a combination of these mo- 
dalities. Hematogenous malignancies 
were treated with chemotherapy. 

Statistical methods. Patients presenting 
with two malignancies are at risk of dying 
from either cancer, or from another cause. 
We used competing risks methodology 
to analyze the cause-specific survival of 
these patients." The probabilities of dy- 
ing from a particular cause, and the con- 
ditional probabilities of dying from a 
particular cause after having survived for 
a specified length oftime, were estimated 
by these methods. Survival times were 
calculated from the time of diagnosis of 
the second malignancy. Median follow- 
up time was estimated from the survival 
of patients still at risk. Between group 
differences in the median values of study 
variables were assessed with rank sum 
tests;^ proportions in contingency tables, 
with the Pearson chi-square test.^' 



Results 

In our study group, the second primary 
neoplasm was diagnosed when patients 
had achieved a median age of 68.7 years 
(range = 38-89 years). Patients were fol- 
lowed for a median of 5.3 years thereaf- 
ter. Of the 158 patients 1 19 were white, 
38 black, and one Asian. Second malig- 



nancies arose in the prostate (in 43 cases), 
bladder (14 cases), kidney (nine cases), 
lung (20 cases), gastrointestinal tract (24 
cases), hematopoietic system (14 cases), 
head and neck (13 cases), and miscella- 
neous (21 cases). 

The interval between diagnosis of 
first and second malignancy varied 
widely. When second neoplasms arose in 
the genitourinary system (prostate, blad- 
der and renal), two-thirds had been noted 
within three months of diagnosis of the 
first cancer. When second cancers were 
of gastrointestinal or lung origin, they 
were found at a median of more than 3.5 
years after the original genitourinary tu- 
mor was diagnosed. Hence, many of the 
double genitourinary malignancies were 
synchronous. Patients with second ma- 
lignancies of gastrointestinal, lung and 
hematogenous origin tended to have rather 
aggressive disease which presented late 
after the diagnosis of the first primary. 
There were enough patients in this group 
to compare their course to those with 



double genitourinary malignancies. 

Competing risks methodology allows 
us to estimate the probability of dying 
from each of the causes of interest, and to 
estimate conditional probabilities of dy- 
ing from a given cause after survival for 
one, two, three and five years. Table 1 A, 
below, shows the results for the overall 
group of 158 patients; Table IB shows 
the results for the group with a genitouri- 
nary second primary (n=66); Table IC, 
those for patients with a gastrointestinal, 
lung, or hematogenous second primary 
(n=58). Column 1 (P^ shows the uncon- 
ditional probability, and columns 2 
through 5, the conditional probabiUties 
(subscripts indicate survival for 1 , 2, 3, or 
5 years). 

For all 1 58 patients, the greatest risk 
of dying came from the second primary, 
but if patients survived at least one year, 
the risk became more evenly spread out 
between the twocancers and other causes. 
Table IB shows that patients who had 
genitourinary second primaries (Group 



Table 1 . Probability that patients with two cancers die from a specific cause 
A. All patients (n=1 58) 



Cause of death 


Po 


P, 


P: 


P3 


P, 


First primary 


.26 


.29 


.28 


.24 


.19 


Second primary 


.41 


.24 


.21 


.17 


.20 


Other causes 


.33 


.29 


.30 


.33 


.20 



B. Genitourinary second primaries (n=66) 



Cause of death 


Po 


P, 


P. 


P3 


P, 


First primary 


.35 


.32 


.30 


.26 


.21 


Second primary 


.15 


.12 


.05 


.03 


.06 


Other causes 


.49 


.41 


.44 


.47 


.32 



C. Gastrointestlnal/lung/hematogenous second primaries (n=58) 



Cause of death 


Po 


P, 


P. 


P, 


P, 


First primary 


.12 


.26 


.31 


.21 


.34 


Second primary 


.65 


.39 


.31 


.21 


.34 


Other causes 


.23 


.24 


.22 


.17 


.00 



Note: Pj is the unconditional probability of dying from one of the listed causes. P^ is the 
conditional probability of dying after a patient has survived for x years (x = 1 ttirough 5) 
follovi^ing the diagnosis of the second cancer. 



NCMJ May/June 1996, Volume 57 Number 3 1 73 



1) were at minimal risk from the second 
cancer at all times; Table 1 C, that patients 
with gastrointestinal, lung, or hematog- 
enous second primaries (Group 2) had an 
increased risk of dying from their second 
cancer early on, but a more even risk of 
dying from any of the causes if they 
survived at least two years. 



Discussion 

The use of advanced radiographic mo- 
dalities (computerized tomography or 
magnetic resonanceimaging) in theevalu- 
ation of genitourinary neoplasms leads to 
the discovery of a multitude of second 
primary malignancies. The second can- 
cers may be of urologic or non-urologic 
origin and may present in a synchronous 
or metachronous fashion. The discovery 
of a second primary neoplasm raises the 
question of which neoplasm represents 
the greatest biologic hazard to the patient. 

We analyzed the clinical course of 
158 patients with genitourinary malig- 
nancy who subsequently developed a sec- 
ond primary neoplasm, using analysis of 
cause-specific survival based on compet- 
ing risks to assess outcome. The median 
age of Group 1 patients (who acquired a 
second primary neoplasm of the prostate, 
bladder or kidney) and Group 2 patients 
(who acquired a second primary of lung, 
gastrointestinal , or hematogenous origin) 
did not differ significantly. But the me- 
dian interval between diagnosis of the 
first and second neoplasms was signifi- 
cantly different (0.8 months in Group 1 
and 46.8 months in Group 2). This may 
reflect the extensive diagnostic survey of 
the genitourinary tract that accompanies 
diagnosis and treaunent of a genitouri- 
nary malignancy. Furthermore, 32 of 68 
patients who underwent cystopros- 
tatectomy forprimary bladdcrcarcinoma 
were found to have prostate carcinoma 
only by step-sectioning the specimen. 
These two factors certainly influence the 
interval between diagnosis of the first 
and second primary genitourinary malig- 
nancy. 

We noted two clinically significant 
findings. 1) The second urologic prima- 
ries in Group 1 were usually found at an 



early stage and the mortal risk conferred 
by the second primary was minimal 
throughout the period of follow-up. On 
the other hand, the non-urologic second 
primaries of Group 2 were found an aver- 
age of 3.5 years after the first. For six 
months after diagnosis, the second pri- 
mary posed the greater risk of death. 
Two-and-a-half years after diagnosis, the 
risk of death from first primary, or the 
second primary, or other causes became 
almost identical. 

To further address the relative risks 
conferred by the first and second cancers, 
we examined the survival of patients who 
presented with two concurrent neoplasms. 
Some investigators define concurrent or 
synchronous double primaries as those 
diagnosed within one year of each other;' 
other authors specify diagnosis within a 



"When death due 

to either the first or 
second primary cancer 

was taken as the 

endpoint, patients had 

a greater mortality from 

the non-urologic second 

primary neoplasm." 



six-month period.'*'^ We used both defi- 
nitions to examine our population since it 
seems probable that a patient with a sec- 
ond primary neoplasm remains at risk 
from the first primary for at least one 
year, regardless of the organ or tissue 
involved. 

Patients who had lung, gasU'ointesti- 
nal, and hematogenous second malig- 
nancies diagnosed concurrently with a 
genitourinary neoplasm were at greater 
risk of death from the non-genitourinary 
primary. This held true even when the 
genitourinary primary was diffusely meta- 
static. When death due to either the first 
or second primary cancer was taken as 
the endpoint, patients had a greater mor- 
tality from the non-urologic second pri- 
mary neoplasm. 

In Group 1, 42 patients presented 
with a primary bladder neoplasm and 



subsequently developed a prostate (39 
cases) or renal cancer (three cases). Four- 
teen of the 42 subsequently died of blad- 
der cancer, and two of prostate cancer, 
but none from renal cancer. In most pa- 
tients the second primary neoplasm was 
found incidentally and was of earlier stage 
and lower grade than the first (only five 
were poorly differentiated tumors; 37 
found were well or moderately well dif- 
ferentiated) which may account for the 
difference in mortality. Of 19 patients 
who presented with prostate cancer and 
were found subsequently to have renal or 
bladder cancer, four died of prostate can- 
cer, four of bladder, and one of renal 
cancer; all prostate cancer dealhsoccurred 
in patients whose disease was metastatic 
at presentation. All deaths from the sec- 
ond primary were due to advanced stage 
bladder cancer. Therefore, in patients with 
double genitourinary malignancies, the 
tumor of more advanced stage and grade 
at diagnosis conferred the greatest risk of 
dying. 

We suspect that several factors ex- 
plain our findings. First, most patients 
who have a urologic tumor get close 
surveillance of the urologic tract, leading 
to early detection of second urologic 
malignanciesata time when these tumors 
are at a low stage and low grade and pose 
a lower risk to the patient. On the other 
hand, patients with second malignancies 
of lung, gastrointestinal, and hematog- 
enous origin are at greater risk, not sim- 
ply because they are found at a later stage, 
but because these are more aggressive 
tumors. For example, even when the uro- 
logic malignancy was of higher stage 
than the nonurologic second malignancy, 
mortality from the nonurologic second 
primary was greater. 

Until now, few reports have looked 
at the relative biologic hazard of double 
malignancies. Selli et al'^ reviewed the 
clinical course of 33 patienis with con- 
current bladder and prostate adenocar- 
cinoma (excluding transitional cell carci- 
nomas of the prostate). In 18 patients, the 
prostate neoplasm was found inciden- 
tally on review of the pathologic speci- 
men after radical cystoprostatectomy for 
primary bladder carcinoma. The authors 
concluded that aggressive surgical treat- 



1 74 NCMJ May/June 1996, Volume 57 Number 3 



ment of organ-confined concurrent tu- 
mors leads to survival equivalent to that 
seen with each tumor considered indi- 
vidually. They also found that transi- 
tional cell carcinoma of the bladder was 
the more aggressive malignancy. Our data 
support their conclusion; our patients with 
second primaries of the bladder fared 
worse than those whose second primary 
was in the prostate. Nevertheless, we 
think that the concurrent urologic tumor 
with the more advanced stage and grade 
is the more lethal. 

Konski et aF' looked at the simulta- 
neous presentation of transitional cell 



carcinoma of the bladder and adenocar- 
cinoma of the prostate in 22 patients. 
Their patients were most likely to die 
from the carcinoma that was most ad- 
vanced at presentation. The authors rec- 
ommended directing treatment at the most 
advanced and aggressive malignancy, 
approaching each patienton an individual 
basis. Our data support this idea. Patients 
with concurrent transitional cell carci- 
noma of the bladder and adenocarcinoma 
of the prostate, usually died from the 
tumor of most advanced stage and grade. 
We conclude that lung, gastrointes- 
tinal, and hematogenous second primary 



neoplasms pose a greater risk to patients 
with a urologic primary than do prostate, 
bladder, and renal second primaries. Pa- 
tients who have a primary prostate, blad- 
der, or renal cancer and a second, syn- 
chronous lung, gastrointestinal, or he- 
matogenous primary, should have the 
latter treated first. Those patients who 
present with a urologic primary neoplasm 
and are subsequently found to have a 
second urologic primary, should have the 
tumor of more advanced stage and grade 
addressed first. □ 



References 

1 Billroth T. Die allgemeine chirurgische 
Pathologie und Therapie in 51 
Vorlesungen. In: Reimer G. Handbook 
fur Studirence und Aerzte. Berlin: G 
Reimer, 1889, p 908. 

2 Warren S, Gates O. Multiple primary 
malignant tumors: a survey of the litera- 
ture and a statistical study. Amer J Cancer 
1932;16:1358-1403. 

3 MoertelCG, Dockerty MB, Baggenstoss 
AH. Multiple primary malignant neo- 
plasms. I. Introduction and presentation 
of data. Cancer 1961;14:221-30. 

4 MatzkinH.BrafZ. Multiple primary ma- 
lignant neoplasms in the genitourinary 
tract: occurrence and etiology. J Urol 
1989;142:1-12. 

5 Moertel CG, Dockerty MB, Baggenstoss 
AH. Multiple primary malignant neo- 
plasms, n. Tumors of different tissues or 
organs. Cancer 1961;14:231-7. 

6 Hajdu SI, Hajdu EO. Multiple primary 
malignant tumors. J Amer Geriatr Soc 
1968;16:16-26. 

7 Lynch HT, Larsen AL, Magnuson CW, 
Krush AJ. Prostate carcinoma and mul- 
tiple primary malignancies: study of a 
family and 109 consecutive prostate can- 
cer patients. Cancer 1966;19:1891-7. 

8 Moertel CG, Dockerty MB, Baggenstoss 
AH. Multiple primary malignant neo- 
plasms, ni. Tumors of multicentric ori- 
gin. Cancer 1961; 14:238^8. 

9 MoertelCG. Multiple primary malignant 
neoplasms: historical perspectives. Can- 
cer 1977;40:1786-92. 

10 Spratt JS Jr. Multiple primary cancers: 
review of clinical studies from two Mis- 



souri hospitals. Cancer 1977;40: 1 806-1 1 . 

1 1 Berg JW, Schottenfeld D. Multiple pri- 
mary cancers at Memorial Hospital 1 949- 
1962. Cancer 1977;40:1801-5. 

12 Newell GR, Krementz ED. Multiple ma- 
lignant neoplasms in the Charity Hospital 
of Louisiana Tumor Registry. Cancer 
1977;40:1812-20. 

13 Selli C, Hinshaw W, Wolfe JA, Paulson 
DF. Management of patients with con- 
current primary tumors of bladder and 
prostate. Urology 1983;21:562-5. 

14 Rao DB, Batina RR, Ray M. Multiple 
primary malignancy in the elderly. J Amer 
Geriatr Soc 1978;26:526-7. 

15 Liskow AS, Romas N, Ozzello L, et al. 
Multiple primary tumors in association 
with prostatic cancer. Cancer 
1984;54:2549-55. 

16 Kantor AF, McLaughlin JK, Curtis RE, et 
al. Risk of second malignancy after can- 
cers of the renal parenchyma, renal pel- 
vis, and ureter. Cancer 1986;58:1 158-61. 

17 Liskow AS, Neugut Al, Benson M, et al. 
Multiple primary neoplasms in associa- 
tion with prostate cancer in black and 
white patients. Cancer 1987;59:380-4. 

18 Winfield HN, Reddy PK, Lange PH. Co- 
existing adenocarcinoma of prostate in 
patients undergoing cystoprostatectomy 
for bladder cancer. Urology 1987;30:100- 
1. 

19 Melvin WV, Parsh S, Murthy RSC, et al. 
Multiple synchronous primary intra-ab- 
dominal neoplasms. J Nat Med Assoc 
1989;81:1177-83. 

20 Sherman KJ, Daling JR, Chu J, et al. 
Multiple primary tumours in women with 



vulvar neoplasms: a case-control study. 
Br J Cancer 1988;57:423-7. 

21 O'Boyle KP, Kemeny N. Synchronous 
colon and renal cancers: six cases of a 
clinical entity. Am J Med 1989;87:691-3. 

22 Libby DM, Altorki NK, Gold J, et al. 
Simultaneous pulmonary and renal ma- 
lignancy. Chest 1990;98:153-6. 

23 Suemasu K, Harris CC, Melamed MR, 
Shimosato Y, Watanabe S, Mukai K, et 
al: Report of the meeting on fundamental 
and clinical research in multiple f)rimary 
cancer, Jpn. J. Clin. Oncol. 1990; 20:436- 
440. 

24 Konski A, Rubin P, Di Santangnese PA, et 
al. Simultaneous presentation of 
adenocarcinoma of prostate and transi- 
tional cell carcinomaof the bladder. Urol- 
ogy 1991;37:202-6. 

25 Wegner HEH. Multiple primary cancers 
in urologic patients: audit of 19-year ex- 
perience in Berlin and review of the lit- 
erature. Urology 1992;39:231-6. 

26 Greven KM, Spera JA, Solin LJ, et al. 
Secondary malignant neoplasms in pa- 
tients with bladder carcinoma. Urology 
1992;39:204-6. 

27 Lawless JF. Statistical Models and Meth- 
ods for Lifetime Data. New York: John 
Wiley and Sons, 1982, pp 484-91. 

28 Armitage P. Statistical Methods in Medi- 
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29 Armitage P. Statistical Methods in Medi- 
cal Research. London: Blackwell Scien- 
tific Publications, 1971, pp 1314. 



NCMJ May/June 1996, Volume 57 Number 3 



175 



CLINICAL PRACTICE 



Improved Hearing Results from 
Stapedotomy with iVIyringotomy 



Chapman T. McQueen, MD, Jason R. Burke, BA, Tracey G. Wellendorf, MD, 
Vincent N. Carrasco, MD, and Harold C. Pillsbury, III, MD, FACS 



Otosclerosis is a disease of the temporal 
bone in which fixation of the stapes 
footplate leads to conductive hearing loss. 
Guild found histologic otosclerosis in 
12% of white women and 6.5% of white 
men over age 54, but in only 1 % of blacks 
of both sexes; otosclerosis was bilateral 
in about 70% of cases.' Otosclerosis is 
rare in Native Americans and half as 
prevalent in Asians as whites." 

The true incidence of otosclerotic 
deafness is not known because histologic 
evidence of otosclerosis docs not always 
imply clinical hearing impairment. Guild 
noted that only 12% of temporal bones 
with histologic disease had stapes 
footplate ankylosis, the hallmark of clini- 
cal otosclerosis. Clinical otosclerosis is 
twice as common in women as in men. 
When present, hearing loss is bilateral in 
90% of patients.^^ 

Surgical u-eaunent of stapes footplate 
fixation dates from 1853 when Toynbee 
first described ankylosis of the stapes 
secondary to otosclerosis.'" Since then 
otolaryngologists have developed sev- 
eral approaches (stapes mobilization, lat- 
eral canal fenestration, large fenestra 
stapedectomy, and small fenestra stape- 
dotomy) to correct the conductive hear- 
ing loss caused by stapes footplate fixa- 



The authors are members of the Division 
of Otolaryngology/Head and Necl< Sur- 
gery, University of North Carolina School 
of Medicine, 610 Burnett Womack BIdg., 
CB# 7070, Chapel Hill 27599-7070. 



tion. Stapedectomy and stapedotomy are 
the most commonly used procedures, and 
small fenestra stapedotomy is considered 
"state of the art," because hearing im- 
proves more with stapedotomy rather than 
stapcdectomy."''''Stapedcctomy involves 
removal of the entire stapes. Stapedotomy 
removes only the stapes suprastructurc 
and a small fenestration is created through 
the footplate. Both require a prosthesis 
from the incus to the oval window to 
reconnect the ossicular chain and trans- 
mit sound. 

Of course, surgery in and around the 
oval window has associated risks: senso- 
rineural hearing loss, perilymph fistula 
(both reportedly less common after 
stapedotomy than stapedectomy); otitis 
media; displacement of the prosthesis 
from the fenestration; ossicular damage, 
such as incus dislocation ; chordae ty mpani 
injury; bleeding; CSF leaks; labyrinthitis; 
tinnitus; vertigo; and meningitis.'^"^ 

Surgical incision of the tympanic 
membrane (myringotomy) is used to di- 
agnose and treat middle ear disease and 
eustachian tube dysfunction. Ventilation 
of the middle ear and drainage of middle 
ear fluid can help prevent chronic ear 
disease. However, myringotomy has been 
avoided at the time of stapes surgery 
because of worries about giving bacterial 
pathogens and other ototoxic substances 
access to the recently fenestrated otic 
capsule. On the basis of the results we 
report here, we propose that myringotomy 
following stapedotomy actually improves 



hearing outcome at no greater risk of 
complications than in patients undergo- 
ing stapedotomy without myringotomy. 



Materials and Methods 

We retrospectively anal yzed the outcomes 
of 31 patients who underwent 34 
stapedotomies at the University of North 
Carolina at Chapel Hill. Patients were 
included based on our ability to docu- 
mentaudiologic follow-up ofone year or 
greater. After reviewing medical charts, 
we constructed a database (Fourth Di- 
mension Relational Database, version 
3.05; ACI US Co.) of information about 
patient age, sex, race, operated ear, side(s) 
operated on, disease process, pre- and 
postoperative complications, pre- and 
postoperative symptoms, attending sur- 
geon, resident surgeon, prosthesis used, 
initial or revision surgery, and complete 
audiometric history at least one year after 
operation. 

Twelve patients underwent 13 
stapedotomies with myringotomy (Group 
I), and 19 underwent 21 stapedotomies 
without myringotomy (Group II). Fol- 
low-up in Group I ranged from 368 to 
1 ,663 days (mean = 734) and in Group II, 
from 487 to 3,284 days (mean = 865). 
There were no significant differences 
between Group I and Group II in any of 
the categories listed above. 

All patients in Group I, and 16 of 
those in Group II, had conductive hearing 



176 



NCMJ May /June 1996, Volume 57 Number 3 



losses secondary to otosclerosis; three 
patients in Group II had congenital stapes 
fixation. Group I consisted of 1 1 whites 
and one black (1 1 women and one man), 
ranging in age from 31 to 68. Group II 
consisted of 18 whites and one black (13 
women and six men), aged 1 1 to 63. In 
Group I there was one bilateral procedure 
and 1 1 unilateral procedures; three op- 
erations were for revision of surgery pre- 
viously done elsewhere. In Group II, there 
were two bilateral and 17 unilateral pro- 
cedures of which four were revisions. In 
three patients, revisions were undertaken 
for surgery done elsewhere and in one, 
for a prosthesis implanted one month 
earlier. Revision operations were neces- 
sary because of adhesions to or displace- 
ment of the prosthesis. 

Patients in both groups were pre- 
medicated with one dose of an intrave- 
nous first generation cephalosporin. The 
operative site was preppcd with betadine 
solution and draped in a sterile fashion. 
Small fenestration stapedotomy was per- 
formed via a trans-canal approach with a 
standard tympanomeatal flap (elevation 
of the tympanic membrane). Each was 
done under general anesthesia by a resi- 
dent physician with a senior faculty mem- 
ber in attendance. Balanced anesthesia 
using a halogenaled inhalation agent ac- 
companied by non-paralyzing intrave- 
nous sedation was used in all cases; ni- 
trous oxide was excluded. Twenty-nine 
patients received a Schuknecht Teflon 
piston prosthesis and two received a 
Robinson bucket-handle prosthesis. In 
Group I, the myringotomy incision was 
made in the anterior-inferior quadrant of 
the tympanic membrane following re- 
placement of the tympanomeatal flap. 

At the completion of the surgery. 



Gelfoam impregnated with antiseptic oint- 
ment was placed in the external auditory 
canal against the tympanic membrane to 
keep the flap in place. Postoperative an- 
tibiotics were given for seven to 10 days, 
and patients were instructed in routine 
postoperative ear care including water 
precautions. At the first postoperative 
visit, the external canal was cleaned gen- 
tly with mild suction. At the second post- 
operative visit, the canal was again cleaned 
and audiograms performed as they were 
at all subsequent visits. Inspection of the 
tympanic membrane showed closure of 
the myringotomy within three to four 
days after surgery. 

Improvement in conductive hearing 
loss was defined as the average closure of 
the gap in air versus bone conduction of 
sound (air-bone gap) at frequencies of 
500, 1000, 2000, and 4000 Hz. Single 
tailed t-tests were used to compare hear- 
ing results between Group I and Group II. 



Results 

Postoperative closure of the average air- 
bone gap was found in both patient groups, 
but the improvement in conductive hear- 
ing loss (defined as percent of closure of 
the preoperative air-bone gap) was greater 
in patients who received myringotomy 
(p<0.05). In Group I, the mean air-bone 
gap fell from 27.69 dB to 4.90 dB (90% 
closure). In Group II, the mean air-bone 
gap fell from 32.0 dB to 15.7 dB (49% 
closure). 

Speech reception threshold and dis- 
crimination scores also improved after 
surgery although the results did not reach 
statistical significance (Table 1, below). 
In Group I patients, the average speech 



reception threshold declined from 45 dB 
to 26.2 dB and discrimination improved 
from 97% to 98.5%. In Group II, the 
average speech reception threshold fell 
from 54.4 dB to 32.5 dB and discrimina- 
tion improved from 96% to 96.8%. Two 
patients in Group II actually had further 
hearing loss after surgery: in one, the air- 
bone gap increased from 38.75 dB to 45 
dB; and in the other, from 31.24 dB to 
32.5 dB. The reason for these adverse 
results was displacement of the prosthe- 
sis in one but was unknown in the other. 
One patient had undergone revision sur- 
gery and was lost to follow-up; the other 
never returned for further intervention. 

We found no difference in outcome 
related to prosthesis type, age of the pa- 
tient, history of eustachian tube dysfunc- 
tion, length of surgery, or length of hos- 
pital stay. No chronic tympanic mem- 
brane perforations were identified in ei- 
ther group. There were no perioperative 
complications in Group I, but two pa- 
tients in Group II (mentioned above) had 
decreased hearing after surgery. 



Conclusion 

Stapedotomy with accompanying myrin- 
gotomy has not been extensively dis- 
cussed in the English literature. Our analy- 
sis suggests a greater closure of preop- 
erative air-bone gaps in patients who un- 
derwent myringotomy at the time of 
stapedotomy. These better results may 
well relate to the known causes of stape- ^ 
dotomy failure. 

Displacement of the stapes prosthe- 
sis leads to hearing loss after stapes sur- 
gery. Assuming that ossicular continuity 
remains intact following surgery, lateral 



Table 1. Patient hearing results 



Preop ABG* 
(dB) 



Postop ABG 

at longest 
follow-up (dB) 



Preop SRT 
(dB) 



Postop SRT 

at longest 
follow-up (dB) 



Preop 

discrimination 
(%) 



Postop 

discrimination 

at longest 
follow-up (%) 



Group I 
Group II 



27.69 
32.0 



4.90 
15.7 



45 
54.5 



26.2 
32.5 



97 
96 



98.5 
96.8 



* Air-bone gap averages calculated by averaging air-bone gaps at 500, 1000, 2000, and 4000 Hz 



NCM J May/ June 1 996, Volume 5 7 Number 3 1 77 



movements of the tympanic membrane 
could displace the prosthesis and pro- 
duce significant conductive loss. Early 
displacement can even take place in the 
operating room if anesthetic agents such 
as nitrous oxide are used.^'^" Nitrous ox- 
ide is approximately 30 times more soluble 
in blood than is nitrogen. It therefore 
enters and occupies air-filled spaces faster 
than nitrogen can be removed." Presum- 
ably, if nitrous oxide is used and eusta- 
chian tube function is abnormal, accumu- 
lation of nitrous oxide within the middle 
ear can force the tympanic membrane 
laterally. Myringotomy at the time of 
surgery would allow escape of nitrous 
oxide, preventing displacement of the 
prosthesis. 

After extubation of the patient, anes- 
thesiologists often apply an oxygen mask. 
On some occasions, positive pressure is 
used after extubation if there is signifi- 
cant residual anesthesia. With glottic clo- 
sure or valsalva, high airway resistance 
can then force air through patent eusta- 
chian tubes into the middle ear. Likewise, 



politzerization (forcing air into the middle 
ear via the eustachian tube) or sneezing 
can force air into the middle ear, leading 
to sudden lateralizing pressures on the 
tympanic membrane. Theseevcnts, which 
occur early in the postoperative period, 
might be averted by intraoperative 
myringotomy. 

Another possible explanation relates 
to the accumulation of fluid within the 
middle ear after surgery. This could lead 
to subsequent otitis media, as has been 
reported following stapes surgery (even, 
on occasion, leading to meningitis).''"'^ 
Myringotomy is commonly used to re- 
lieve acute otitis media and chronic effu- 
sion, and Newland states that myrin- 
gotomy is indicated in certain cases of 
otitis media following stapes surgery. Of 
course, myringotomy at the time of 
stapcdotomy might allow pathogens into 
the middle ear and into the inner ear via 
the fenestration. However, the Gelfoam 
with antiseptic ointment placed against 
the tympanic membrane provides an an- 
tiseptic barrier that acts as a "ball valve" 



to allow exit of gas and fluid while pre- 
venting entry of pathogens. We found no 
evidence of chronic perforations in either 
group despite myringotomies performed 
in Group I. All myringotomies healed 
within three to four days, which is not 
surprising since myringotomies often 
close quickly with few long-term se- 
quelae. 

Our study is limited by the relatively 
small number of patients and the non- 
randomized design. Length of follow-up 
in Group II patients was longer than in 
Group I, but the mean number of days to 
the longest follow-up differed by only 
131 days. The preponderance of women 
in our study should not effect results since 
hearing outcome was independent of sex. 

Small fenestration stapedotomy for 
stapes footplate fixation is the present 
surgical standard for correction of 
otosclerosis-associated conductive hear- 
ing loss. We believe that myringotomy at 
the time ofsurgery significantly improves 
hearing results compared to stapedotomy 
without myringotomy. □ 



References 

1 Guild SR. Histologic otosclerosis. Ann 
Otol Rhinol Laryngol 1944;53:246-66. 

2 Donaldson JA, Snyder JM. Otosclerosis. 
In: Cummings CW, Frederickson JM, 
Marker LA, Krause CJ, Schuller DE, eds. 
Otolaryngology-Hcad andNeck Surgery, 
2nded. Boston: Mosby-Year Book, Inc., 
1993, pp 2997-3016. 

3 Nager FR. Pathology of the labyrinthine 
capsule and its clinical significance. In: 
Fowler EP Jr, ed. Medicine of the Ear. 
New York: Thomas Nelson & Sons, 1 947, 
chapter VII. 

4 Shambaugh GE. Otolaryngology, Vol. 2. 
Hagerstown, MD: WF Prior Co., 1960, 
chapter 2, p 12. 

5 Cawthome T. Otosclerosis. J Laryngol 
1955;69:437-56. 

6 Altmann F, Glasgold A, Macduff JP. The 
incidence of otosclerosis as related to 
race and sex. Ann Otol Rhinol Laryngol 
1967;76:377-92. 

7 Friedmann I. Pathology of the Ear. Ox- 
ford: Blackwell Scientific, 1974. 

8 Levin G, Fabian P, Stahle J. Incidence of 
otosclerosis. Am J Otol 1988;9:299-301. 

9 NagerGT. Histopathology of otosclerosis. 
Arch Otolaryngol 1969;89:341. 



10 Toynbee J. Case of complete bony 
ankylosis of the stapes to the fenestra 
ovalis. Trans Pathol Soc London 1853; 
4:253. 

11 Fisch U. Stapedotomy versus stape- 
dectomy. Am J Otol 1982;4:112-7. 

12 Marquet J, Creten WL, Van Camp KJ. 
Consideration about the surgical approach 
in stapedotomy. Acta Otolaryngol 
1972;74:406-10. 

13 Smyth GDL, HassardTH. Eighteen years 
experience in stapedectomy: the case of 
the small fenestra operation. Ann ORL 
1978;SuppI 49:87. 

14 Bailey HA, Pappas JJ, Graham SS. Small 
fenestra stapedectomy technique reduc- 
ing risk and improving hearing. Otol Head 
and Neck Sur 1983;March:5 16-20. 

15 Causse JB, Causse JR, Wiet RJ, Yoo TJ. 
Complications of stapedectomies. Am J 
Otol 1983;4:275-80. 

16 MatzGJ.LockhartHB, Lindsay JR. Men- 
ingitis following stapedectomy. Laryngo- 
scope 1968;78:56-63. 

17 Wolff D. Untoward sequelae eleven 
months following stapedectomy. Ann Otol 
1964;73;297-304. 

1 8 PalvaT, Palva A, Karja J. Fatal meningitis 



in a case of otosclerosis operated upon 
bilaterally. Arch Otolaryngol 1972;96: 
130-7. 

19 Brown JS. Meningitis following stapes 
surgery. Laryngoscope 1967;77:1295- 
303. 

20 Newlands WJ. Poststapedectomy otitis 
media and meningitis. Arch Otolaryngol 
1976;102:5M. 

21 Davis I, Moore JRM, Lahari SK. Nitrous 
oxide and the middle ear. Anesthesia 
1979;34:147-51. 

22 Johnson LP, Prkin JL, Stevens MH, Otto 
WC, McCandless GA. Action of general 
anesthesia on middle ear effusions. Arch 
Otolaryngol 1980;106:100-2. 

23 Shaw JO, Stark EW, Gannaway SD. The 
influence of nitrous oxide anaesthetic on 
middle ear fluid. J Laryngol Otol 
1978;92:131-5. 

24 Starr A, SchwartzJaoin P. Cochlear mi- 
crophonic and middle ear pressure changes 
during nitrous oxide anesthesia in cats. J 
Acoust Soc Am 1972;51:1367-9. 

25 Patterson ME, Bartletl PC. Hearing im- 
pairment caused by intratympanic pres- 
sure changes during general anesthesia. 
Laryngoscope 1976;86:399-404. 



178 



NCMJ May I June 1996, Volume 57 Number 3 



North Carolina Society of Addiction Medicine 

(achapter of the American Society of Addiction Medicine) 

Annual Meeting and Scientific Seminar 

open to all interested members of the medical profession 

2:00-4:00, Friday June 21, 1996 (2 CME hours) 

CityFair Building, Suite 214 

211 N. College Street, Cliarlotte (uptown) 

"Cutting Edge Issues in Addiction Medicine" 

Mark S. Gold, M.D. 

Professor, University of Florida Brain Institute 
Nationally known lecturer, author and researcher 

In conjunction with UNC-C Charlotte's 4th Annual McLeod Institute on Substance Abuse 

For more information about the organization and its activities, contact: 
James F. Alexander, MD, President, c/o NCSAM Secretariat, NC Governor's Institute on Alcohol 
and Substance Abuse, Inc., Box 13374, Research Triangle Park, NC 27709, phone 919-990-9559 
or fax 919-990-9518 




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Research 

mc. 



CLINICAL PRACTICE 



Treatment of Benign Cutaneous 
Vascular Proliferations 
With the 585-nm Flashlamp-Pulsed 
Tunable Dye Laser 

Aleksandar Krunic, MD, PhD, Carlos Garcia, MD, Greg Viehman, MD, and Robert E. Clark, MD, PhD 



Benign cutaneous vascular proliferations 
(BCVPs) may be congenital and acquired 
(Table 1, below).' ^ Common congenital 
lesions include hemangiomas and port- 
wine stains (sometimes called vascular 
malformations, nevus flammcus, or 
"stork-bite"); common acquired lesions 
include telangiectases, spider angiomas, 
cherry angiomas, and angiofibromas. 

In the 1 960s, lasers were used to treat 
BCVPs, but the results were disappoint- 
ing because of widespread thermal injury 
to, and significant scarring of, adjacent 
normal tissue. S ince 1 986, when the Food 
and Drug Administration approved use 
of the flashlamp-pulsed tunable dye laser 
(FPTDL), it has become the instrument 



Table 1. Classification of benign 
cutaneous vascular proliferations 

Congenital port-wine stains (vascular 

malformations, nevus 
flammeus, stork bite) 
hemangiomas 

Acquired telangiectasia 

spider angiomas 
cherry angiomas 
angiofibromas 



The authors are with the Dermatologic Surgery 
Unit, Box 3915, Duke University Medical Center, 
Durham 27710. 



of choice. It is possible with this laser to 
specifically target hemoglobin and blood 
vessels, resulting in selective thermolysis 
with little or no damage to the surround- 
ing dermis, epidermis, or adnexal struc- 
tures. 



Types of Benign 
Cutaneous Vascular 
Proliferations 

Port-wine stains (PWSs) are red, blue, or 
purple discolorations of the skin on one 
side or in the midline of the head and neck 
(Figure la, next page). Rarely, they may 
be bilateral or involve adjacent der- 
matomes or be associated with 
Icptomeningeal lesions (Sturge- 
Weber syndrome). PWSs are 
caused by abnormally ectatic 
blood vessels with no prolifera- 
tion of endothelial cells. They 
are almost always presentat birth 
and evolve with a steady, pro- 
gressive course. They occur in 
0.3% of both sexes. As the pa- 
tient ages, port- wine stains may 
darken or develop small nod- 
ules on the surface. They may 
bleed after slight u-auma, espe- 
cially when located in the mouth. 
Even very small PWSs on the 
face and anterior neck may pro- 



duce significant cosmetic disfigurement, 
impairing the individual'sself-esleem and 
social interactions. 

Telangiectases are superficial, vis- 
ible vessels of the skin (Figure 2a, next 
page) and are found in linear, arborizing, 
spider, or papular forms. Factors that 
contribute to their development include 
anoxia, hepatic insufficiency, and preg- 
nancy. Cherry angiomas are usually seen 
on the trunk; angiofibromas, on the face. 



Principles of 
FPTDL Therapy 

The light that makes up a laser beam 
differs from conventional light in its in- 
tensity, coherence, and monochromatic- 
ity.'' The 585-nm wavelength (yellow 
light) of the FPTDL closely approximates 
the 577-nm absorption peak of hemoglo- 
bin, but is far removed from the absorp- 
tion spectrum of melanin. This permits 
selective destruction of dermal blood 
vessels up to a depth of 1 .2 mm. Use of a 
pulse duration of 450 usee (shorter than 
the time required for heat generated in the 
target tissue to fall by 50%) also produces 
selective thermolysis of dermal vessels. 
After treatment with the FPTDL, dermal 
blood vessels show agglutination of red 
blood cells and intravascular thrombosis; 
in approximately one month there is re- 



180 



NCMJ May /June 1996, Volume 57 Number 3 




Fig 1 a (left): Port-wine stain on the left cheek and lip at the mandibulary division of the trigeminal nerve in 26-year-old female patient. 
Fig 1b (right): Significant lightening of port-wine stain on cheek of same patient after three sessions with FPTDL, energy level 6.5 
J/cm.^ Posterior part of the port-wine stain has noticeable scarring from previous argon laser therapy. 



growth of normal -appearing new vessels 
with minimal scarring. The level of tissue 
injury can be controlled by delivering 
different densities of laser energy . Higher 
energy levels are used to treat adults and 
patients with hypertrophic PWS. Lower- 
energy densities generally suffice in the 
treatment of small-vessel telangiectases 
and in infants and young children.' 



Treatment with 
the FPTDL 

We use the SPTL-IA instrument (Can- 
della Corp., Wayland, MA) which emits 
450 (xsec pulses of light at a wavelength 
of 585 nm. The pulses may be focused on 
2, 3, 5, or 7 mm spots depending on the 
size of the area to be treated. Treatment' ■'•' 



usually begins with non-overlapping 
pulses directed at a 2 cm-4 cm^ test site. 
This allows the family and the patient to 
understand the procedure and become 
familiar with the postoperative bruised 
appearance of the treated site: The skin 
becomes gray-black foraweek to lOdays 
after the procedure (Figure 3, next page). 
Some physicians omit the use of a test site 






Fig 2a (left): Telangiectases on the left cheek in 43-year-old female patient. Fig 2b (right): Almost complete disappearance of facial 
telangiectases in same patient after single treatment with FPTDL with energy level 6.0 J/cm.^ 



NCM J May I June 1996, Volume 57 Number 3 



181 




Fig 3: Immediate postoperative bruising after treat 
merit of congenital hemangioma. 



and proceed to complete treatment from 
the start, depending on the willingness of 
the patient and the parents to accept post- 
operative bruising. 

Treatment may be performed with or 
without local or general anesthesia.' Lo- 
cal anesthesia may be achieved by topical 
application of aeutectic mixture of 2.5% 
lidocaine and 2.5% prilocaine cream 
(EMLA cream) under occlusion for 30- 
60 minutes, or by local or regional infil- 
tration with 2% lidocaine without epi- 
nephrine. Immediately after the FPTDL 
treatment, treated skin is covered with ice 
packs to eliminate postoperative discom- 
fort and warm sensation of the skin. If 
crusts develop, patients may apply anti- 
biotic ointment to the skin. Sun protec- 



tion is recommended.'* 

Treatments are usually re- 
peated at one- to three-month 
intervals untit the lesion is com- 
pletely lightened. If there is no 
significant decrease in redness, 
the energy density may be in- 
creased at subsequent sessions. 



Complications 

Complications are extremely 
rare. They include atrophic scar- 
ring (reported in 0.8% of cases), 
hyperpigmentation ( 1 %), hypo- 
pigmentation (2.6%) and der- 
matitis (0.04%).' Only atrophic 
scarring is permanent, and der- 
matitis can be easily controlled 
with topical corticosteroids. Pa- 
tients with light skin usually 
respond very well to FPTDL 
treatment; those with very dark skin may 
have sufficient energy absorption by 
melanin that there is subsequent peeling 
of the epidermis and decreased clinical 
response. 



Specific Treatment 
Outcomes 

Most studies show about 75% lightening 
of PWSs after two or three treatments 
(Figure lb, previous page).'"' Clinical 
responses are slightly better with lateral 
rather than midfacial lesions. FPTDL 
treatment should be started as early in life 
as possible. 

Telangiectases are usually com- 



pletely cleared after one treatment (Fig- 
ure 2b, previous page).'' Because most 
lelan-giectases are small, children toler- 
ate FPTDL treatment of these acquired 
lesions quite well even without anesthe- 
sia. 



Cost 

The Candella SPTL- 1 A laser costs about 
$180,000; replacement dye kits cost 
$1,000/500 pulses; the yearly service 
contract costs about $20,000.'° This over- 
head expense considerably limits the 
availability of this treatment. However, 
the significant psychological and medi- 
cal benefits of treatment will probably 
lead to increased use, thereby decreasing 
costs and making treatment more acces- 
sible. The cost of each treatment varies 
from $800 to $1,300 depending on the 
size of the lesion. 



Comment 

A number of treatments' have been used 
to remove BCVPs — surgery, radiation, 
sclerotherapy, freezing, tattooing with 
fiesh-colored pigments, dermabrasion, 
and electrotherapy. The ruby laser, argon 
laser, CO^ laser, and Nd:Yag laser have 
all been tried, but the problem of low 
selectivity resulting in postoperative scar- 
ring has limited their efficacy. The 
FPTDL, because of its selective pho- 
tothermolysis, few complications, and 
reasonable cost has become the treatment 
of choice for BCVPs, especially in 
children. □ 



References 

1 Pratt AG. Birthmarks in infants. Arch 
Dermatol 1953;67:302-5. 

2 Jacobs AH, Walton RG. The incidence of 
birthmarks in the neonate. Pediatrics 
1976;8:218-22. 

3 Redisch W, Pelzer RH. Localized vascu- 
lar dilatations of the human skin: capil- 
lary microscopy and related studies. Am 
Heart J 1949;37:106-14. 

4 Bean WB. Vascular spiders and related 
lesions of the skin. Springfield, IL: Tho- 
mas, 1958, p 372. 



5 Alster T, Tian Tan O. Laser treatment of 
benign cutaneous vascular lesions. Am 
Fam Phys 1992;44:547-54. 

6 Enjolras O, Muilliken JB. Tlie current 
management of vascular birthmarks. 
Pediatr Dermatol 1993;10:311-33. 

7 GeronimusRG. Pulse dye laser treatment 
of V ascular lesions in children. J Dermatol 
Surg Oncoll993; 19:303-10. 

8 Taieb A, Touati L, Cony M, et al. Treat- 
ment of portwine stains with the 585-nm 
flashlamp-pulsed tunable dye laser: a 



study of 74 patients. Dermatology 
1994;188:276-81. 
9 Levine VJ, Geronimus RG . Adverse ef- 
fects associated with the 577- and 585- 
nanometer pulsed dye laser in the treat- 
ment of cutaneous vascular lesions: a 
study of 500 patients . J Am Acad Dermatol 
1995;32:613-7. 
10 Goldman MP, Fitzpatrick RE. Treatment 
of cutaneous vascular lesions. In: Cutane- 
ous Laser Surgery. St. Louis, MO: Mosby, 
1994, pp 19-105. 



182 



NCMJ May I June 1996, Volume 57 Number 3 




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Gayle Beth Thomas (FP), Piedmont Health 

Services, 30 1 Lloyd St., Carrboro 275 1 6 
Alan Thomas Villavicencio (RES), 361 1 

University Drive, #6J, Durham 27707 

Beaufort-Hyde-Martin- 
Washington-Tyrrell 

Keith Gerald Hutton Schroeder (R), Sea- 
board Radiology, 630 E. 1 1th St., Wash- 
ington 27889 

Buncombe 

Todd Herman Hansen (CD), P.O. Box 

7239, Asheville 28802 
Mark Hedrick, Blue Ridge Bone & Joint 

Clinic, PA, 129 McDowell St., 

Asheville 28801 
Charles Henry Mitchell, IV (PD), 191 

Biltmore Ave., Asheville 28801 
Charles Forrest Murray (GP), 35 Woodfm 

St., Asheville 28801 

Burke 

Mark McManus, 103 Medical Heights 
Drive, Morganton 28655 



Cabarrus 

Cathryn L. Crosland, 1054 Burrage Road, 

NE, Concord 28025 
Celia B . Entwistle, 65 1 Church St., North, 

Concord 28025 
William Glenn Masius (EM), 5807 

Wingate Way, Concord 28025 

Catawba 

Alfred Earl Geissele (ORS), 1621 Fifth St. 
Drive NW, Hickory 28601 

Cleveland 

John Charles Stuart Dawson (FP), 608 W. 
Kings St., Professional Park Bldg. #2, 
Kings Mountain 28086 

Craven-Pamlico-Jones 

Richard Dwight Grady (OTO), Coastal 
ENT/Facial Plastic Surgery, 1315 
Tatum Drive, New Bern 28560 

David Harold Sharkis (IM), P.O. Box 68, 
PollocksviUe 28560 

Cumberland 

Ramona V. Anderson (PD), 3625-5 Pine 

Lake Drive, Fayetteville 28305 
Charles Wesley Ford, Jr. (OTO), 237 

Longvue Drive, Ste. A, Fayetteville 

28311 
Rajesh Khurana (FP), 640Levenhall Drive, 

Fayetteville 28304 
Michael G. Woodcock (OPH), 1726 

Metromedical Drive, Fayetteville 28304 

Davidson 

Daniel Mark Entwistle (PD), 200 Arthur 
Drive, Thomasville 27360 

Durham-Orange 

James Campbell Cusack, Jr. (GS), UNC, 

3010 Old Clinic Bldg., CB# 7210 

Chapel Hill 27599 
Farrell Owen Mendelsohn (RES), 112 

Briarcliff Road, Durham 27707 
Richard Kenneth Serra(EM), lOBeckford 

Place, Durham 27705 



184 



NCMJ May/June 1996. Volume 57 Number 3 



Forsyth-Stokes-Davie 

Robert Edmond Bechtold (DR), Bowman 
Gray, Dept.Of Radiology, Medical Cen- 
ter Blvd., Winston-Salem 27157 

Alfred Dudley Bell (RES), 2304 Rose- 
wood Ave., Winston-Salem 27 1 03 

Chris Nicholas Christakos (FP), 3821 
Forrestgate Drive, Winston-Salem 
27103 

John Franklin Davis (FP), 382 1 Forrestgate 
Drive, Winston-Salem 27103 

Darryl Lynn Landis (FP), 7990 North Point 
Blvd., Ste.lOO, Winston-Salem 27106 

Richard Gene Reuhland (OBG), 1806 S. 
Hawthorne Road, Ste.102, Winston- 
Salem, 27103 

Gregory Peter Temas (OPH), 3333 
Brookview Hills Blvd., Suite 206, Win- 
ston-Salem 27103 

Jean-Claude Veille (OBG), Bowman Gray 
School of Medicine, Medical Center 
Blvd., Winston-Salem 27157 

Franklin 

Patrick Dennis Mullen (GS), 1 22 Jolly St., 
Ste. 102, Louisburg 27549 

Gaston 

Keith Alan Ayrons (HEM), 2563 Pem- 
broke Road, Gastonia 28054 

Greater Greensboro Soc. of Med. 
Ernest A. Christopher Andree (PTH), P.O. 

Box 2747, Greensboro 27402 
EricJonKozlow(A), lOOWestwoodAve., 

High Point 27262 
Deborah Denise Schoenhoff (IM), 5209 

Ainsworth Drive, Greensboro 27401 

Harnett 

Ronald Stanley Levey (ORS), 700 
Tilghman Drive, #3702, Dunn 28334 

SheelaKizhakethalakal Thomas (IM), Cen- 
tral Medical Associates, 925 E. Singh 
Plaza, P.O. Box 779, Benson 27504 

Henderson 

Richard Kendall Shelton (R), 807 Justice 

St., Hendersonville 28739 
Andrew Henderson Wells (R), 507 

Claremom Drive, Flat Rock 28731 

High Point 

Donald Lee Decoy (PUD), 624 Quaker 
Lane, Ste. C-106, High Point 27262 

Richard Michael Don Diego (IM), 624 
Quaker Lane, High Point 27262 



Steven Phillips Irving (MFS), 420 Edgedale 

Drive, High Point 27262 
Wendell Stephen Myers (R), P.O. Box 

5007, High Point 27262 
Jonathan David Pliiman (PUD), 624 

Quaker Lane, Ste. C-106, High Point 

27262 

Iredell 

Michael Hamilton Schlesinger (U), 706 
Hartness Road, Statesville 28677 

Lee 

Steven Brian Gallup (FP), 555 Carthage 
St., Sanford 27330 

Mecklenburg 

Jeanne Ellen Ballard (OBG), 1015 Lyeriy 
Ridge Road, Concord 28027 

Michael Jay Davidson (IM), Carolinas 
Medical Center, 1000 Blythe Blvd., 
Charlotte 28203 

Mark Stephen Forshag (CCM), P.O. Box 
3286 1 , Carol inas Medical Center, Char- 
lotte 28232 

Mark John Heitbrink (FP), 1201 1 Stoney 
Meadow Drive, Mint Hill 28227 

Eric Brian Laxer (ORS), 1918 Randolph 
Road, Charlotte 28207 

David Scott Moss (IM), 101 W.T. Harris 
Blvd., #3301, Charlotte 28262 

Hugh Neal Northcott (OBG), 105 12 Park 
Road, Charlotte 28210 

Sheley R. Revis (IM), 125 Baldwin Ave., 
Charlotte 28204 

Cheryl Reis Robertson (IM), 201 Provi- 
dence Road, Ste. 103, Charlotte 28207 

Mona D. Shah (PD), 7801 Pineville- 
Matthews Road, Charlotte 28226 

Gregory Robert Weidner (IM), 
Mecklenburg Medical Group, 3535 
Randolph Road, Ste. 300, Charlotte 
28211 

Pamela Burkholder Young (PD), P.O. Box 
338, Matthews 28106 

Moore 

Michael Ray Morris (OTO), Pinehurst Sur- 
gical Clinic, 1 Memorial Drive, 
Pinehurst 28374 

Nash 

Alfred Jenkins Covington, Jr. (A), 3301 
Sunset Ave., #A, Rocky Mount 27804 

New Hanover-Pender 

Christopher Collins Barber (IM), 2425 S. 



17th St., Ste. 101, Wilmington 28401 
AlexGarhoe Yip (AI), 2321 Delaney Ave., 
Wilmington 28401 

Pasquotank-Camden-Currituck-Dare 

Mark Christopher Rummel (GS), 1 134 N. 
Road St., Elizabeth City 27909 

Pitt 

Barbara Aldridge (STU), 301 -A Alice 

Drive, Greenville 27834 
Joseph Dolby Babb (C), ECU School of 

Medicine, PCMH, Rm. 352, Greenville 

27858 
Lynda Lorraine Basnight (PD), ECU 

School of Medicine, Dept. of Pediat- 
rics, Brody Bldg., Greenville 27858 
Andora Bass (STU), 132-A Oakmont 

Drive, Greenville 27858 
Dena Carver (STU), 802-23 Treybrooke 

Circle, Greenville 27834 
William Henry Harrison Chapman (GS), 

ECU School of Medicine, Dept. Sur- 
gery, PCMH, Rm. 245, Greenville 

27858 
Sheila Clark (STU), 1200 Treybrooke 

Circle, Greenville 27834 
Victor Collins (STU), 1 28-A Huntingridge 

Road, Greenville 27834 
Moahad Dar (STU), 115 Heritage St., 

Greenville 27834 
Jeffrey Frazier (STU), 305 Lindell Drive, 

Greenville 27834 
Karen Gavigan (STU), 1 1 2-E Breezewood 

Drive, Greenville 27858 
Michael Hadnagy (STU), 108 Hunters 

Lane, Greenville 27834 
Kenneth Harris (STU), 1541 Treybrooke 

Circle, Greenville 27858 
Deborah Hauser (STU), P-1 Doctors Park 

Apts., Greenville 27834 
Benjamin Huneycutt (STU), 1002-34 

Treybrooke Circle, Greenville 27834 
Thomas Jones, III (STU), 200-B Lindbeth 

Drive, Greenville 27834 
Terry Kersey, Jr. (STU), 207 N. Eastern 

St., Greenville 27858 
Anessa Lewis (STU), 1606 Treybrooke 

Circle, Greenville 27834 
Christopher Marinakis (STU), 213 

Pineridge Drive, Greenville 27834 
Jay Menke (STU), 107 Dupont Circle, 

Greenville 27858 
Linda Miller (STU), Route # 1 , Box 204-B, 

Blounts Creek 27814 
Daniel Moore (Pm), Regional Rehabilita- 
tion Ctr., 2100 Stantonsburg Road, 



NCM J MaylJune 1996, Volume 57 Number 3 



185 



Greenville 27858 
James Moore (STU), 105 Stanton Drive, 

Greenville 27834 
Vicki Morrow (STU), 27 11 -A E. Second 

St., Greenville 27858 
Sidney Myles (STU). PO Box 1262, 

Robersonville 27871 
John Edwin Nichols, Jr. (OBG), 2305 Ex- 
ecutive Park West, Greenville 27834 
David Parker (STU), 204-B Lindbeth 

Drive, Greenville 27834 
SangnyaRanchrodbhaiPatel(IM),PCMH- 

TA-340, Greenville 27834 
Travis Perry (STU), 412-B Paladin Drive, 

Greenville 27834 
Dan Powell (STU), 901-34 Treybrooke 

Circle, Greenville 27834 
Sharon Robinson (STU), 141 Duke Road, 

Winterville 28590 
Roytesa Rodgers (STU), 3103 Sherwin 

Ct., Apt. 8, Greenville 27834 
Vincent Leigh Sorrcll (CD), ECU School 

of Medicine, Section of Cardiology, 

Greenville 27858 
Shelly Styons (STU), 107-E Breezewood 

Drive, Greenville 27856 



Lorraine Tafra (GS), ECU School of Medi- 
cine, Greenville 27858 
Beth Ann Taterosian (STU), 802-22 

Treybrooke Circle, Greenville 27834 
Steve Thomas (STU), 204 Whittington 

Circle, Greenville 27834 
Kenneth Tiffany (STU), 506-33 

Treybrooke Circle, Greenville 27834 
Joseph Umesi (STU), 3368 Tobacco Road, 

Apt. #12, Greenville 27858 
Bobby Walters, Jr. (STU), 510-34 

Treybrooke Circle, Greenville 27834 
Roxie Wells (STU), 400-N Paladin Drive, 

Greenville 27834 
Ralph Emerson Whatley (IM), ECU School 

of Medicine, 3E-111 Brody Bldg., 

Greenville 27858 

Randolph 

Robert Alan Robbins (FP), White Oak 

Family Phys., PA, 550 White Oak St., 

Ashcboro 27203 
Ivcy Williamson (IM), Randolph Medical 

Associates, 132-A W. Miller St. 

Asheboro 27203 



Richmond 

Mark Steven Isserman (IM), P.O. 
1537, Rockingham 28379 



Box 



Robeson 

Julio Tallet (IM), 395 
Lumberton 28358 



W. 27th St., 



Surry-Yadkin 

Roland Leon Boyd (PD), 708 S. South St., 
Mount Airy 27030 

Wake 

Carrie Deener Alspaugh (D), 102 West 
Seve Court, Morrisville 27560 

John Douglas Knoop (OTO), Healthsource, 
4000 Aerial Center Parkway, 
Morrisville 27560 

Walter Tony Koscielniak, III (PD), Ra- 
leigh Pediatric Associates, 4905 Pro- 
fessional Court, Raleigh 27609 

Brett Michael Macaluso (PD), 4905 Pro- 
fessional Court, Raleigh 27609 

Joseph John Mignogna (OM), Glaxo 
Wellcome Inc., Five Moore Drive, Re- 
search Triangle Park 27709 




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186 



NCMJ MaylJune 1996, Volume 57 Number 3 



Classified Ads 



DURHAM, NC : Fi ve well-established and busy internists seek 
a BC/BE inemist to replace retiring senior partner. Attrac- 
tive benefits. Salary negotiable. Send CV to: Steven H. 
Hirsch, MD, 2609 N. Duke St., Suite 205, Durham, NC 
27704. 

EQUIPMENT FOR SALE: Outfit your office with previ- 
ously owned/refurbished medical equipment and save 40%- 
50% the cost of all new equipment. Defibrillators, EKG, 
oximeters, lights, oto-opthalmoscopes, gumeys, etc. All 
equipment is checked by our bio-med department with full 
warranties! Call Ben at Southeastern Medical Systems, 800/ 
562-7137. 

FAMILY PRACTITIONER/URGENT CARE (BC/BE): 

Immediate opening to join multispecialty group in the Triad 
metropolitan area of North Carolina. Excellent financial 
package with minimum guarantee and performance based 
above minimum. Ideal location, group-owned and managed 
by fellow physicians in private practice. Easy access to the 
mountains and ocean. Excellent area to live and raise a 
family. Send resume to or call: Michael Reece, 507 Lindsay 
St., High Point, NC 27262, 910/8834453 ext. 167, or 910/ 
883-0029. 

FOR SALE: Kirkland-Glover retirement sale of assorted gyn 
office equipment, including a 1992 Elmed 170 LEEP gen- 
erator. Write or call: Jack Kirkland, MD, 1012 Salem St., 
Wilson, NC 27893, telephone 919/243-6087. 

MEDCONNECT: Physician to patient 800# voice messaging 
service lets you deliver, in your own voice, test results or 
other information with one phone call. Patients love retriev- 
ing your messages at their convenience, 24 hours a day, 
seven days a week. Call 1-800-576-5146 or e-mail 
kkems@i2020.net and find out how easy it is to subscribe to 
Medconnect. Why not take a "test drive" of Medconnect 
right now! 

• To listen to a patient's message dial 1-800-636-7978 

• Type in this social security number: 069-38-7504 

• Type in this "pin" number: 1# 

• And while you're at it, try these other "pin" numbers: 2#, 3#, 

4#, 5#, 6#. 



PENDER COUNTY HEALTH DEPARTMENT: desires 
Phvsician III: salarv range $95.68 1-$l 24.990. Requirements : 
graduation from an accredited school of medicine and comple- 
tion of residency or specialized training and one year of 
experience in the practice of medicine, or four years of 
experience in the practice of medicine. Special require- 
ments : must be a Family Practice Physician and eligible for 
licensure to practice medicine in North Carolina, and be so 
licensed before permanent appointment All applicants must 
complete and submit an original PD107 State Application 
obtained at the Employment Security Commission along 
with a copy of current license. Doctorate degree, and any 
other specialized training to: Gwen Smith, Administrative 
Assistant, Pender County Health Department, P.O. Box 
1209, Burgaw, NC 28425, 910/259-1230. Posiuon open 
until filled. 

STATESVILLE: Varied opportunities in "home town" com- 
munity of 40,000 (draw area 100,000) near Charlotte and 
Winston-Salem. Hospital-sponsored Convenient Care Cen- 
ter (help design it) with stable hours, no call, or traditional 
office setting and shared call (1:4). Highly competitive 
income guarantee or the security of a salary. Thriving 
economy. Lake Norman (500-mile shoreUne), and North 
Carolina's fifth-highest per capita income. Contact Kevin 
Allen at 800/873-4583, or fax CV to 704/872-7924. 

PHYSICIANS NEEDED: Positions available in Raleigh and 
Durham for uncomplicated office practice. Flexible full- or 
part-time hours available. Low stress. Retired, semi-retired 
okay. Competitive compensation. Malpractice covered. Call 
Leona McKlveen at 919/833-6865. 



Classified rates: For North Carolina Medical Society 
members, $25 for the first 25 words, 35 cents for each 
additional word; for non-members, $35 for the first 25 
words, 35 centsfor each additional word. Send no advance 
payment or purchase order. You will be billed separately. 
Mail ad copy and complete billing information to: Nortii 
Carolina Medical Journal, Box 3910, DUMC, Durham, NC 
2771 0, fax: 91 9/286-921 9, e-mail: yohnOOOl @mc.duke.edu 



NCMJ May/ June 1996, Volume 57 Number 3 



187 



Aphorisms 
of the Month 

Daniel J. Sexton, MD, Editor 

"Folk Wisdom, Part 1" 



An army of sheep led by a lion would defeat an army 
of lions led by a sheep. — Arab proverb 

Be on your guard against a silent dog and still water. 

— Latin proverb 

Beware of the young doctor and the old barber. 

— Benjamin Franklin 

Deceive the rich and powerful if you will, but don't 
insult them. — Japanese proverb 

Forget injuries, never forget kindnesses. 

— Chinese proverb 

If Jack's in love, he's no judge of Jill's beauty. 

— Benjamin Franklin 

In reviling, it is not necessary to prepare a preliminary 
draft. — Chinese proverb 



It is not enough to aim: you must hit. 



Italian proverb 



Live together like brothers and do business like 
strangers. — Arab proverb 

Three things it is best to avoid: a strange dog, a flood, and 
a man who thinks he is wise. — Welsh proverb 

To change and change for the better are two different 
things. — German proverb 

To know the road ahead, ask those coming back. 

— Chinese proverb 

When you throw dirt, you lose ground. 

— Texan proverb 

Fax aphorisms to Dr. Sexton at 919/684-8358 



Index to Advert 


isers 


Biomedical Editors 




171 


Century American Insurance Co. 


inside front cover 


ClinTrials Research, Inc. 




179 


CompuSystems, Inc. 




back cover 


CPO Prosthetics & Orthotics 




122 


Deloilte & Touche, LLP 




123 


The Doctors' Company 




161 


GTE Mobile One Net 




141 


Healthcare Consulting Group 




183 


Interim Physicians 


- 


186 


Jeremy Cay /The Hammocks, SC 




147 


MAG Mutual Insurance Co. 




121 


Medical Billing Practice, Inc. 




167 


Medical Mutual Insurance Co. 




125 


Medical Protective Co. 




151 


Medstaff, Inc. 




160 


NCDEHNR Vaccine Program 




164 


NC Primary Care Network, Inc. 




145 


NC Society of Addiction Medicine 




179 


Pfizer Pharmaceuticals 




139 


Triad Radiographic Imaging 




171 


T. Rowe Price Investment Services, Inc. 


135, 157 


US Air Force 


inside back cover 


US Air Force Reserve 




165 


US Army Reserve 




131 


US Naval Reserve 




183 



1 88 NCM J May /June 1 996, Volume 5 7 Number 3 




SPECIALIZE 

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What can a map tell you about a computer system? 



Plenty — if, Hke this one, it shows 
how many medical offices in the 
CaroUnas use a particular practice 
management system to run more 
efficiently, effectively, and profitably. 

For example, it might show how 
a 16-year commitment to "Working 
for Physicians" has resulted in over 
800 installations in North and South 
Carolina. 

It might bring home how features 
like "on-tlie-fly" refiling, encounter- 
form tracking, and direct transmission 
to North Carolina Medicare, 
Medicaid, and Blue Cross / Blue Shield 
(with no per-daim charges) are 
improving physicians' revenue. 



It could clarify how critical "one- 
call" support can be in helping offices 
stay productive — how telephone 
support staff, software and hardware 
engineers, technicians, trainers, and a 
fleet of service vans can provide 
support unmatched in the industry 

It might demonstrate how on- 
going research and development 
brought innovations like the first 
integrated, direct electronic claims 
transmission in a practice 
management system. 

Or it could validate the concept of 
regional focus: By selling systems 
only in the Southeast, a computer 
company can keep customers up-to- 



date on the latest insurance filing 
requirements. 

It could emphasize the flexibility 
of multi-user, multi-tasking software 
that runs on the most popular 
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And it could illustrate the value of 
having a computer vendor with a 
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ij|y/August1996 

plume 57 
'<jmber4 



(. 



North Carolina 



Medical Journal 

For Doctors and their Patients 




SPECIAL ISSUE: 



A Healing Hand 

Physician Impairment 
and tfie Road to Recovery 



Robert C. Vanderberry, MD, Guest Editor 



r At Century American, We 11 Guide 1 
1 You Through The Unknown. J 




flr When it comes to group practice 
liability coverage, some programs might 
leave you lost. Century American's group 
coverage policies are designed to meet 
your needs based on the way your group 
practices medicine in today's changing 
medical profession. 

Unlike other companies just now 
entering the group protection arena, 



Century American has firsthand experience 
in solving the unique issues facing physician 
group practices. Our claims defense team, 
risk management experts and team of 
customer-driven specialists make group 
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it's been our specialty since 1986. 



Unless you compare programs, you 
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choosing professional liability coverage. The 
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Since 1938. Crumpton Company has served the 
professional insurance needs of North Carolina 
Physicians with conspicuous excellence. Recently. 
Crumpton merged with J. Southgate and Son 
(est. 1872) and Home Insurance Agency (est. 1914) 
to create CSC. Our new Company stands poised to 
offer you a vastly expanded portfolio of insurance 
brokerage and asset management services. 

But one thing hasn't changed ... the quality service, 
unrivaled integrity and personal attention you've 
come to expect from your insurance company. 

In the coming months you'll hear more about how 
our new synergy can add value to your practice. 
We're counting on exceeding your expectations. 

CSC Corporation. Your newest oldest insurance 
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Medicine Has 
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C R P R A T I 



NORTH CAROLINA 
MEDICAL JOURNAL 

For Doctors and their Patients 



EDITOR 

Francis A. Neelon, MD 

DEPUTY EDITOR 

Edward C. Halpcrin, MD 

CONSULTING EDITOR 

Eugene A. Slead. Jr., MD 

ASSOCIATE EDITORS 
Eben Alexander, Jr., MD 

Winslon-Salcm 
William B. Blyihe, MD 

Chapel Hill 
F. Maxion Mauney, Jr.. MD 

Asheville 
James P. Weaver, MD 

Durham 

MANAGING EDITOR 

Jeanne C. Yohn 

phone: 919/286-6410 

fax: 919/286-9219 

e-mail: yohn0001@mc.duke.edu 

BUSINESS MANAGER 

Donald R. Wall 



SECTION EDITORS 
Eugene W. Linfors, MD 
Daniel J, Sexton. MD 

EDITORIAL BOARD 
CHAIR 

Margaret N. Barker, MD 
Morehead City 

MEMBERS 

Jack Hughes. MD 

Durham 
PaLnck D. Kenan. MD 

Durham 
Assad Meymandi, MD 

Raleigh 
William G. Porter, MD 

Charlotte 
MaryJ. Raab, MD 

Greenville 
C. Stewart Rogers, MD 

Greensboro 
J. Dale Simmons, MD 

Raleigh 
TTiomas G. Stovall, MD 

Winston-Salem 



July/August 1996, Volume 57, Number 4 

Published bimonthly as the official organ of the 

North Carolina Medical Society (ISSN 0029-2559). 

222 N. Person St., P.O. Box 27167, Raleigh, NC 2761 1-7167 

The Society is not to be considered as endorsing the views and opinions advanced by authors of 
papers delivered at the Annual Meeting or published m the official publication of the Society. — 
ConsUluUon and Bylaws of the North Carolina Medical Society. Chap. IV, Section 3, pg. 4. 



NORTH CAROLINA MEDICAL JOURNAL 

Kditorial office: Box 3910, Duke University Medical Center, Durham, NC 27710, (phone: 
919/286-6410, fax: 919/286-9219, e-mail: yohn0001@mc.duke.edu). is owned and published 
by the North Carolina Medical Society under the direction of its Editorial Board. Copyright© 
1996 North Carolina Medical Society. Address manuscripts and communications regarding 
editorial matters, subscription rates, etc.. to the Managing Editor at the Durham address listed 
above. (Use the following address for overnight and express mail lo the editorial ofice only: 
2200 W. Mam St.. Suite B-210. Room \2,Durham,KC Z7105. )Usicd in Index Medicus. Ml 
advertisements arc accepted subject lo the approval of the Editorial Board of the North Carolina 
Medical Journal. The appearance of an advertisement in this publication does not constitute any 
endorsement of the subject or claims of the advertisement. 

Advertising representative: 

Don French. 318 Tweed Circle. Box 2093. Cary. NC 2751 1. 919/467-8515. fax: 919/467-8071 
Printing: The Ovid BeU Press. Lie. 1201-05 Bluff St.. Fulton. MO 65251. 800/835-8919 

Annual subscription (6 /oHrmi/ issues): $20 (plus 6% sales ux = $21.20). Single copies: $3.50 
regular issues. $5 special issues. Roster: $55 (plus 6% sales ux). Second-class postage paid at 
Raleigh NC 27601 , and at additional mailing offices. 

POSTMASTER: SEND ADDRESS CHANGES TO THE NORTH CAROLINA 
MEDICAL JOURNAL, P.O. Box 27167, RALEIGH, NC 27611-7167. 



THE ARMY RESERVE OFFERS UNIQUE AND 
REWARDING EXPERIENCES. 




As a medical officer in the Army Reserve you will be offered a 
variety of challenges and rewards. You will also have a unique 
array of advantages that will add a new dimension to your 
civilian career, such as: 

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• advanced casualty care 

• advanced trauma life support 

• flight medicine 

• continuing medical education programs and conferences 

• physician networking 

• attractive retirement benefits 

• change of pace 

It could be to your advantage to find out how well the Army 
Reserve will treat you for a small amount of your time. An Army 
Reserve Medical Counselor can tell you more, call collect : 

800'USA'ARMY 



ARMY RESERVE MEDICINE. BE ALL YOU CAN BE: 



orth Carolina Medical Journal 

FOR DOCTORS AND THEIR PATIENTS 

July/August 1996, Volume 57, Number 4 

Cover: Original artwork by Bill Herrin, Designhaus, Wake Forest. 



Robert C. Vanderberry, MD 

Jonnie //. McLeod, MD 

Anonymous 

Anonymous 

Wilmer C. Belts, MD 



Special Issue: 

A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

196 Positioning a Safety Net for Physicians and Their Patients 

201 Our Brothers' Keepers: A History of the North Carolina Physicians Health Program 

204 The Riddle of the Chemically Dependent Physician: Heartbreak or Joy? 

208 A Case of Professional Sexual Misconduct 

214 Psychiatric Diagnoses in North Carolina Physicians Health Program Participants 

218 The Contrast Between Physicians Seen by the Medical Board and Those Seen in Private Practice 

Nicholas E. Stratas, MD. FAPA 
230 A North Carolina Medical Board Member Looks at the North Carolina Physicians Health Program 

Charles E. Trade, MD, FAPA 
233 Physician Assistant Impairment: A Peer Review Program for North Carolina 

Daniel E. Mattingly, PA-C, and L. Gail Curtis, PA-C 
236 Physician Prescribing of Controlled Drugs: Perspectives of the NC Medical Board and the Stale Bureau of Investigation 

Donald Pittman and R. Keith Bulla 

242 Front Line Recovery: Motoring Across North Carolina Carsten Thuesen, CSAC 

243 Into the Next Century: A Strategic Plan for the North Carolina Physicians Health Program 

Julian F. Keith, Jr., MD 



246 



FIRST-PERSON PHYSICIAN 

Anger/ Avarice/ Angst: A Report From the Malpractice Battlefield 



James A. Bryan, II, MD 



PERSPECTIVES OF MEDICINE 

249 Liver Transplantation: Patient Selection and Organ Allocation 

James F. Trotter, MD, J. Gregory Fitz, MD, and Pierre A. Clavien, MD, PhD 

253 Radial Keratotomy: What Is It? Where Did It Come From? What Has Happened With It in the United States? 
Bill Satterwhite. III. JD, MS IV 



225 



HEALTH WATCH 

Low Back Pain: Help Is Available 



Ranjan S. Roy. MD. PhD 



BULLETIN BOARD 

192 Letters to the Editor 
200 Instructions for Authors 
216 Subscription Form 
258 Classified Advertisements 



260 New Members 

262 CME Calendar 

264 Aphorisms of the Month 

264 Index to Advertisers 



NCMJ July! August 1996, Volume 57 Number 4 



191 



Letters to the Editor 



^ 



An Open Letter to the 
North Carolina Medical Board 
Dear Board Members: 

At a recent seminar, I heard the July 22, 1995, Position 
Statement of the North Carolina Medical Board ("The Physi- 
cian-Patient Relationship, the Physician, and the North Caro- 
lina Medical Board") mentioned favorably. I have to admit that 
I had given the Statement only momentary attention when I first 
got it, but I have since re-read it. 

In this Statement, the Board quite correctly emphasizes the 
patient responsibilities we all share as physicians, and it quite 
correctly emphasizes the fact that contractual obligations to a 
third party do not absolve physicians of those responsibilities. 
But the Board has lost contact with reality if it thinks that it has 
fulfilled its own responsibilities merely by issuing this state- 
ment. In fact, I believe that it has incurred an even greater 
responsibility by so doing. 

These are unfortunate facts of modem medical life, but 
true: Every day physicians are harassed by managed care 
organizations (MCOs) demanding that doctors minimize the 
number and variety of medical services they provide to patients. 
Physicians are threatened regularly with "deselection" if they 
fail to meet the MCO goals of reduced costs. They are exposed 
to malpractice suits when bad outcomes occur, even outcomes 
that are the direct result of policies of the MCOs and beyond the 
physician's control. 

It is unfortunately also true that a process of "Darwinian 
selection" of physicians by the MCOs "weeds out" and eventu- 
ally eliminates those very physicians who are willing to make 
(in the Board's words) "communication, patient primacy, con- 
fidentiality, competence, patient autonomy, compassion, self- 
lessness, and appropriate care" the standards by which they 
practice medicine. This point was made quite forcefully by a 
physician whose ejection from a "provider panel" was briefly 
famous late last year.' 

The point I want to make is that on one side we see a 
ravenous health care industry, greedy for profits and able to 
extract those profits much more easily when physicians can be 
forced to act unethically toward their patients; on the other, 
physicians whose livelihoods are threatened if they fail to meet 
the contractual restrictions that the MCOs impose. And all the 
while, those MCOs are protected by antitrust provisions from 
collective action by physicians! 

Unfortunately, the Board addressed its Position Statement 
not to the MCOs, but to physicians who have much less 



leverage, much less power. The Board would do a far greater 
service to the citizens of North Carolina if it behaved as good 
physicians should and attacked the cause of the disease rather 
than its symptoms. If bad conQ-acts cause bad physician behav- 
ior, then deal with the contracts! The content of all such 
contracts is entirely subject to law, and to regulation by the 
Insurance Commissioner. If the legislature and the Commis- 
sioner can be convinced that bad contracts foster bad medicine, 
perhaps they will have the sense and integrity to eliminate them 
(although we may be sure the MCOs will fight tooth and claw 
to keep them). The Board should be trying to convince both the 
legislature and the Commissioner. 

The North Carolina Medical Board may say that attempt- 
ing to influence the regulation of managed care contracts falls 
outside its charge. I do not doubt that, in a formal way, this is 
correct. Nor do I doubt that the Board has no budget for such 
activity. But I believe that it is fair to say that the Board does 
have a moral obligation to oppose clear threats to the health and 
well-being of the citizens of this State. This obligation is no less 
sacred than that of individual practitioners toward their pa- 
tients. A body composed of experts in regulation of health care, 
empowered to certify the fitness of practitioners to provide that 
health care, certainly can have an impact should it choose to 
identify and expose dangerous trends such as these. There is no 
reason why contracts that endanger patients — or the physician- 
patient relationship — should be allowed to exist It is time for 
the Board to make itself heard, and not only by physicians. 

David D. Grove, PhD, MD 
1511 Westover Terrace 
Greensboro, NC 27408 

Reference 

1 WoolhandlerS, Himmelstein DU. Extreme risk; the new corporate proposi- 
tion for physicians. N Engl J Med 1995;333:1706. 

Response from Dr. Walter Roufail, 
Immediate Past President, NCMB: 

Dr. Grove'schari table description of the "unfortunate facts 
of modem medical life" is factual and pragmatic. The quandary 
of physicians who adhere to their Hippocratic Oath and the 
realities of modem corporate medicine is not only an issue in 
our state, it is receiving national and media attention (although, 
in my view, slanted toward highlighting the economic greed 
rather than the ethical responsibilities of physicians). 

Dr. Grove's observations about the limitations imposed on 
the NCMB by law and its budgetary capabilities are also quite 



1 92 NCMJ July/August 1996, Volume 57 Number 4 



accurate. Let me emphasize that the NCMB is appointed by the 
Governor of North Carolina and, as such, is a de facto agency 
of the state, mandated and constrained by specific legislative 
acts (in this case, the Medical Practice Act under which the 
NCMB fulfills its duties). In essence, the NCMB exists to 
license physicians and physician extenders on the basis of their 
demonstrated competence and to sanction them, if necessary, 
on the basis of immoral, unethical, or incompetent behaviors. 

The Medical Practice Act gives the NCMB no authority to 
regulate financial transactions between physicians, patients, 
and third-party payers. The NCMB, however, may act on 
financial matters in cases bordering on fraud and abuse. The 
regulation of contracts between physicians and third-party 
payers (now mostly MCOs) falls and is presently within the 
domain of the Department of Insurance. Furthermore, the 
NCMB and all occupational licensing boards in this state are 
specifically prohibited by law from expending funds for lobby- 
ing either the legislature or any administrative agencies. 

Having highlighted those restrictions under the law, I must 
point out that state government agencies are often asked by the 
legislature, other agencies, and boards about their positions on 
certain matters. In the case of MCOs, the NCMB has discussed 
the issues with all who have asked, including the Department of 
Insurance, the Board of Pharmacy, and the Nursing Board. Its 
public and professional members share the concerns of the 
public in general about certain aspects of MCOs and physicians 
and their extenders, in particular as to the points so eloquently 
raised by Dr. Grove. 

The NCMB, by issuing its statement on "The Physician- 
Patient Relationship," which has received a favorable response 
in NC and nationally, was motivated, I think, by two factors. 

First, it hoped to notify physicians and their extenders that 
the NCMB was aware of the pressures presented by the current 
(and future) economic situation. There is no doubt that by 
calling on health professionals to uphold patient advocacy, the 
NCMB has made itquiteclear to all, in and out of the profession, 
that the ethical standards governing the physician-patient con- 
tract supersede any form of economic contract. 

Second, we hoped that by confronting the issue at any early 
phase in the regulation of MCOs in this state, that concerned 
professionals would come forward with a "call to arms" such as 
Dr. Grove's letter. 

The most effective way to express those concerns, how- 
ever, is through organized medicine and the public (patients) 
speaking out to the legislature and the Department of Insurance. 
It is appropriate for citizens, and the duty of professionals, to 
lobby their government in matters that may affect the health and 
welfare of the citizens of North Carolina. 

Should the legislature decide to delegate any regulatory 
functions concerning MCOs to the NCMB, it will lawfully 
comply. 

Walter M. Roufail, MD, Immediate Past President 

North Carolina Medical Board 

P.O. Box 20007 

Raleigh, NC 27619 



In Gratitude 
To the Editor: 

Dr. Ncclon's memorial in the March/April Journal (NC 
Med J 1996;57:1 14) was nearly everything I'd like to tell the 
world about my mom, Jane Whalen. I'm damn proud of mom 
and one of the greatest comforts I can take from losing her is that 
her special qualities were not lost on the world. She made a 
difference. 

I keep Dr. Neelon's column in my briefcase and have read 
it and re-read it on many planes as I've traveled on business 
during the past few months. It has given me great comfort 

In addition to the memorial in the Journal, I also thank the 
North Carolina Medical Society for its tribute to mom. She 
cared deeply about the work she did and, more importantly, the 
people she did it with. 

Robert E. Whalen, II, CFA 

Second Vice President, Securities 

Jefferson-Pilot Life Insurance Company 

P.O. Box 20407 

Greensboro, NC 27420 

From the Editor: 

Ms. Whalen, who passed away last year, was iht Journal's 
editorial assistant. In April, the NCMS Executive Council 
presented the Whalen family with a plaque inscribed with a 
resolution written in honor of her contributions to the Journal. 

Running and the Rules of the Road 
To the Editor: 

I enjoyed reading Dr. Greg Davis' paper in [he. Journal, "A 
Body to Die For" (NC Med J 1996;57: 140). I once had a similar 
experience with a jogger while driving on a two-lane country 
road. In my case a girl was running in my lane toward me at the 
same time that another car was approaching in the opposite 
direction. 1 was going slowly enough that I could come to a full 
stop by the time we met. It was summer — no ice. I couldn't 
believe it but there she was, jogging in place just in front of my 
bumper and only reluctantly did she finally move off to the side. 
She acted as though she expected me to back up and then drive 
out and around her. 

This somewhat chubby girl obviously needed the exercise, 
and perhaps she hadn't done enough running to realize that even 
on a quiet country road there were occasional cars. Her conduct 
could have been related to exercise-induced euphoria, but I 
blamed it on her lack of common sense. At least that's what I 
told her with all the force I could muster! 

Paul L. Bunce, MD 

970 Fairfield Drive 

Chapel Hill, NC 27514 

MCOs: One Physician's Primer 
To the Editor: 

Until I read "Can We Serve Two Masters: The Ethics of 
Managed Care Practice" in the March/April Journal (NC Med 
J 1996;57:80-2), I did not fully realize how my technique for 



NCMJ July/ A ugust 1996, Volume 57 Number 4 1 93 



dealing with managed care organizations (MCOs) had evolved. 
Others may not find my methods applicable, but I'll share what 
I have done. 

1. A very capable and trusted office assistant and I review 
each new managed care contract. The assistant then keeps track 
of who is part of which plan. There are so damn many MCOs 
that I don ' t even try to keep them straight. I remember the plan 
affiliation of a handful of my patients, but I never remember the 
details of their conU'acts. I could not accept a risk control 
contract with this relatively cavalier attitude. 

2. Payments are mailed to me, and I see that they get 
deposited in the bank. This makes me somewhat less likely to 
embezzle funds than might be expected from my attitude (see 
1). I see the gross amounts of the management fees, but I 
otherwise ignore the details of payment. Occasionally 1 glance 
at the section marked "disallowed," and if a particular loss 
seems egregious, I refer it back to my office assistant and we 
will complain, sometimes rather vigorously. 

In 32 years of practice, I have given away about $1.1 
million of care that was not compensated for one reason or 
another — even at the beginning of my career (before Medicare 
and Medicaid) when an office visitcost $4. 1 don' t think that any 
more charges are being "disallowed" now than before when 
they were simply marked "unpaid." Of course, I am sometimes 
angered by the true deadbeat (collection systems have a very 



valid function), but by and large, I consider this a small price to 
pay for my own integrity and peace of mind. 

3. The patient and I decide whether to seek consultation or 
referral. Neither of us asks the MCO. Once the decision is made, 
we may need to choose a specified consultant, sometimes to our 
mutual chagrin. I have never been denied the right to refer a 
patient for consultation, but MCOs have aggravated the pro- 
cess, especially with their use of "authorization numbers" and 
restrictions on surgery. 

It is in the area of consultation/referral that a conscientious 
gatekeeper can "be both the patient's advocate and a cost 
container." One of the biggest wastes in medicine is the patient's 
self-referral to an expensive specialist for a minor problem that 
could easily and efficiently be handled by a much less expen- 
sive visit to a family doctor. 

The relationship between referring and consulting physi- 
cians is important and occasionally subUe. I depend on my 
consultants for knowledge and skills that 1 do not possess. They 
depend on me to deliver primary care. The reason they went into 
specialty practice in the first place was at least in part because 
they didn't want to deliver primary care. A mutual understand- 
ing of roles in this partnership in patient care is one of the most 
gratifying and enjoyable aspects of medicine. 

John R. Dykers, Jr., MD 

P.O. Box 565 

Siler City, NC 27344 



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Charting the Course of History 
To the Editor: 

The North Carolina Maritime History Council is a not-for- 
profit educational organization. Its annual journal. Tributaries, 
is devoted to and promotes the state's maritime history. Re- 
cenUy I read an article by Dr. Marvin Rozear about the state's 
first hospital at Portsmouth Island (NC Med J 1991;52:271-4). 
This article is very pertinent to our interests and to this year's 
journal theme. I would like permission to reprint this article in 
our publicadon. 

Rodney Barfield 

Director, North Carolina Maritime Museum 

Editor, Tributaries 

315 Front SL 

Beaufort, NC 28516 

From the Editor: 

We were delighted to grant Mr. Barfield permission to 
reprint this article in his publication. Tha Journal has published 
two additional articles about Portsmouth Island, and the history 
of medical practice there: NC Med J 1993;54:38-40 and NC 
Med J 1995:56:554-5). 



Send letters to: North Carolina Medical Journal, Box 
391 0, Duke University Medical Center, Durham, NC2771 0, 
fax: 919/286-9219, e-mail: yohn0001@mc.duke.edu 



194 



NCMJ July/August 1996, Volume 57 Number 4 




"It's a good feeling having 
someone in my court." 

"Getting squeezed from both ends isn't 
pleasant. Losing sleep over professional 
liabilities isn't why I studied to be a medical 
professional. When questions 
of accountability arise, it 
seems everyone has their 
representative except 
the doctors. 

Medical Mutual has 
alv^ays been there. 
Even when the 
others pulled out. That 
means a lot. First, and foremost, 
it means that 1 can concentrate 
on my patients needs instead 
of worrying about liability 
insurance. Medical Mutual is 
in my court. Always has 
been. That's a good feeling." 



Medical Mutual 



Medical Mutual Insurance Company 
of North Carolina 

4505 Falls of the Neuse Road 

PO Box 98028 

Raleigh, NC 27624-8028 

Tel: (919)872-7117 

(800)662-7917 

Fax:(919)878-7550 



FROM THE GUEST EDITOR 



Positioning a Safety Net for 
Piiysicians and Tiieir Patients 

Robert C. Vanderberry, MD 



Over the years, the North Carolina Medical Journal has de- 
voted special issues to topics of major consequence to the 
practice of medicine. It is especially appropriate that an issue be 
devoted to physician impairment and recovery since the North 
Carolina Medical Society (NCMS) is one of the nation's leaders 
in rehabilitating physicians. Ever since the American Medical 
Association (AMA) held its first conference on physician 
impairment in 1972, North Carolina's medical leaders have 
faced this issue squarely and have been willing to admit that a 
problem exists. In December 1988, the North Carolina Physi- 
cians Health and Effectiveness Program (now known as the NC 
Physicians Health Program or NCPHP) was established be- 
cause of the joint efforts of the NCMS and the North Carolina 
Medical Board (NCMB). 

During the past seven years the NCPHP has helped more 
than 600 physicians. The magnitude of this number indicates 
the tangible reality of physician impairment and the need for 
intervention, treatment, and rehabilitation efforts as a safety net 
for physicians and their patients. 



The Faces of Impairment 

When NCPHP began in 1988, we expected that chemical 
dependency would be the problem most commonly encoun- 
tered among physicians. This has indeed been borne out; 
65%-70% of participants have had drug or alcohol problems. 
This percentage is similar to that seen in the other programs 
included in the Federation of State Physician Health Programs 
(FSPHP). Table 1, at right, shows that alcoholism was consis- 
tently the greatest problem, accounting for 195 of our first 600 
cases (32.5%). Most physicians with a solitary diagnosis of 
alcoholism were older than age 40 when they enrolled in the 
program. Polydrug abuse accounted for the second largest 

Dr. Vanderberry is Medical Director, North Carolina Physicians 
Health Program, 4700 Six Forks Road, Six Forks Center I, Suite 
220, Raleigh 27609. 



group, and most of these physicians were under age 35. 

Tied for third in frequency was opiate/analgesic depen- 
dency. This is a very interesting group because most of these 
physicians grew up in alcoholic homes and were dead set 
against using alcohol. They "discovered" opiates after dental 
restoration or other surgical procedures. These people might 
have been alcoholic had they chosen to drink alcohol; instead 
they avoided alcohol, but found another drug to use. Also tied 
for third in frequency were the psychiatric disorders. Major 
depression heads the list by a margin of 2:1 or greater. 

Fourth in frequency was the category "Other." This in- 
cludes a wide variety of conditions but one problem, behavioral 
disruption, predominates. Thirty-two of the 68 cases in this 
category are those of disruptive physicians. The increasing 
frequency of this type of referral may necessitate its classifica- 
tion as a separate category. It is commonly believed that 



Table 1. Diagnoses in 


the first 600 




NC Physicians Health 


Program 


participants 


Diagnosis 






Total in program 


Impairment due to aging 




1 


Alcohol use 






195 


Amphetamine use 






2 


Barbiturate use 






5 


Benzodiazepine use 






5 


Cocaine use 






9 


Dual diagnosis 






31 


Marijuana use 






3 


Opioid/analgesic use 






72 


Polydrug use 






80 


Psychiatric disorder 






72 


Sedative/hypnotic use 









Sexual misconduct 






44 


Other 






68 


Unsubstantiated 






13 


Total 






600 



1 96 NCMJ July/August 1996, Volume 57 Number 4 



disruptive physicians have a personality disorder or some other 
psychiatric condition, but that is not so clear. More and more, 
physicians are frustrated by the present-day practice of medi- 
cine. They act out the frustrations of being displaced by comput- 
ers, scanners, HMOs, PPOs, DRGs, QA, risk management, and 
third-party payers. They do not feel in control of the practice of 
medicine; they are unhappy; many are retiring at a very early 
age, creating a maturity gap in medicine. 

The fifth most common diagnosis was that of professional 
sexual misconduct, which refers to instances in which physi- 
cians became involved in homosexual or heterosexual behavior 
with their patients (see article on page 208). The issue of 
professional sexual misconduct is now a "hot item" being 
addressed by medical boards and specialty societies. 

Who Becomes Impaired? 

People often think that impairment is largely a problem in older 
physicians and anesthesiologists. Table 2 indicates the break- 
down of North Carolina participants by specialty. It is evident 
that General Practice was sharply overrepresented. There are 



only 263 general practitioners left in North Carolina and 44 of 
them were enrolled in the NCPHP, a ratio six limes higher than 
would be exjxjcied if these doctors were seen in proportion to 
their numbers. Over the years. Emergency Medicine and Psy- 
chiatry have been two specialties that have generally been 
overrepresented by at least 2 to 1 ; the data in Table 2 (below) 
demonstrate odds ratios of 1.8 and 2.1 for these specialties, 
respectively. Anesthesia (1.6) and Ob/Gyn (1.6) have odds 
ratios that are significantly elevated by statistical test. 

Physician assistants appear to be underrepresented in this 
series (odds ratio = 0.5), but they were only added to the NCPHP 
monitoring process in 1994 (see related article on page 233). 
Truly underrepresented specialtiesare Dermatology (odds ratio 
= 0.2), Pathology (0.2), and Internal Medicine (0.7). The odds 
ratios for all other specialties were not significanUy different 
from 1 .0 than expected by chance. 

The average age of 600 physician enrollees was 43.7, 
indicating that most had been in practice for 10 to 20 years. 
However, since 65 residents were enrolled in the program , there 
is no doubt that impairment can occur early in one's career and 
is no respecter of age. 



Table 2. Specialty breakdown of the first 600 NC Physicians Health Progra 


m participants 






Number 


Percent of 


Number 


Percent of 


Specialty 


In NCPHP 


NCPHP 


practicing in NC 


practitioners 


Anesthesia* 


34 


5.6 


627 


3.6 


Dermatologyt 


2 


0.3 


347 


2.0 


Emergency Medicine* 


33 


5.5 


559 


3.2 


ENT 


8 


1.3 


234 


1.4 


Family Medicine 


66 


11.0 


1759 


10.2 


General Practice* 


45 


7.5 


263 


1.4 


Internal Medicinet 


75 


12.5 


3054 


17.7 


Neurology 


10 


1.6 


232 


1.3 


Neurosurgery 


7 


1.1 


117 


0.7 


Nuclear Medicine 


2 


0.3 


14 


0.1 


Ob/Gyn* 


45 


7.5 


828 


4.8 


Occupational Medicine 


4 


0.6 


68 


0.4 


Ophthalmology 


9 


1.5 


395 


2.3 


Orthopaedics 


22 


3.6 


529 


3.1 


Pathologyt 


3 


0.5 


362 


2.1 


Pediatrics 


30 


5.0 


1098 


6.4 


Physician Asslstantst 


19 


3.1 


1148 


6.7 


Plastic Surgery 


3 


0.5 


105 


0.6 


Psychiatry* 


63 


10.5 


962 


5.6 


Radiation Therapy 


3 


0.5 


74 


0.4 


Radiology 


11 


1.8 


361 


2.1 


Residents* 


65 


10.8 


1820 


10.6 


Surgery 


30 


5.0 


937 


5.4 


Urology 


11 


1.8 


317 


1.8 


Others 





0.0 


1000 


5.8 


Total 


600. 


99.4 


17210 


99.7 


'The odds ratio for representation of this 


specialty is significantly (p<0.01) greater than 1 C 


by Chi-square test. 




tThe odds ratio for representation of this specialty is significantly (p<0.01 ) lower than 1 .0 I 


3y Chi-square test. 





NCMJ July/ August 1 996, Volume 57 Number 4 1 97 



What Leads to Impairment? 

The question often comes up as to why educated physicians 
who have "seen it all" in their training and practices fall prey to 
impairment. I believe that there is no more demanding profes- 
sion than medicine. Its long hours, life and death decisions, and 
stress are all precursors to impairment. Although most impair- 
ment occurs after 10 to 20 years of practice, burnout can occur 
at any age and create impairment. The FSPHP believes that both 
genetic predisposition and a dysfunctional family of origin are 
precursors to impairment. These factors are the baggage that we 
take with us to medical school and that set us up for impairment. 
One or both parents of most of the chemically dependent 
physicians in our series were themselves chemically depen- 
dent. These physicians were caretakers and caregivers long 
before they entered the doors of medical school. It was only 
natural for them to go into one of the helping professions 
(medicine, nursing, social work, and the clergy). Is it surprising 
that those in health care professions become impaired if to 
genetic predisposition we add long hours, life-and-deaih deci- 
sions, and stress? Is this like dehydrated mashed potatoes 
waiting for water? 

The increasing numbers of ever more unhappy physicians, 
the ever-increasing numbers of physician impairment cases, the 
daily changes in the practice of medicine, all raise the question 
of whether medicine is a sick profession. I don't think so, but I 
do think that physicians need to become proactive on their own 
behalf. They need to support reform in house staff training and 



a more humanistic approach to learning, instead of endorsing a 
process that resembles an endurance contest. Physicians need to 
stop cutting comers for the sake of expediency lest they find 
themselves running in circles. They need to learn to say no, 
especially how to say no without feeling guilty. They need to 
identify workaholism in themselves and in others, and to un- 
derstand that in the long run medicine is not the most important 
thing in life. They need to observe the wisdom of the acronym, 
HALT — never become too Hungry, Angry, Lonely or Fired. 

This special issue of the Journal touches on aspects of 
physician impairment, physician rehabilitation, and physician 
health. There are anonymous, first-person accounts by an 
alcoholic practitioner and by a psychiatrist guilty of profes- 
sional sexual misconduct. A past president of the NCMB and a 
present Board member discuss their thoughts about the NCPHP. 
A field coordinator for the NCPHP relays his observations of 
the process of monitoring physicians across North Carolina. A 
SBI agent and the director of investigations for the NCMB 
collaborate to tell about prescribing irregularities by physi- 
cians. The past president of the NC Academy of Physician 
Assistants and the PA member of our Board discuss the struggle 
to bring PAs under the NCPHP umbrella. The NCPHP Board 
chair discusses psychiatfic cases and dual diagnosis cases that 
have been seen over the past seven years. Finally, a NCPHP 
Board member looks to the future and the role that NCPHP — 
and all of us — can and must play if we are to prevent impair- 
ment, rather than treating physicians after impairment has 
begun its devastation. □ 




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198 



NCMJ July/August 1996. Volume 57 Number 4 



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Instructions for Authors 



The North Carolina Medical Journal is a medium for 
communication with and by members of the medical com- 
munity of this state. The Journal publishes six times a year: 
in January, March, May, July, September, and November. 
The Journal will consider for publication articles relat- 
ing to and illuminating medical science, practice, and his- 
tory; editorials and opinion pieces; letters; personal ac- 
counts; poetry and whimsical m usings; and photographs and 
drawings. Papers that relate to the present, past, or future 
practice of the health professions in North Carolina are 
especially pertinent, but manuscripts reflecting other per- 
spectives or topics are welcomed. Prospective authors should 
feel free to discuss potential articles with the editors. 



Manuscript Preparation 

Prepare papers according to the "Uniform Requirements for 
Manuscripts Submitted to Biomedical Journals" (N Engl J 
Med 1991;324:424-8) with the following exceptions: 1) no 
abstract is needed; 2) no running title is needed; and 3) report 
measurements in metric units; use of the International Sys- 
tem of Units (SI) is optional. 

Submit a cover letter and either a 3 1/2-inch hard disk or 
5 1 /4-inch floppy computer disk that contains the text written 
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the text (e.g. no variations in type size, no bold face, no 
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Submit illustrations, in duplicate, in the form of high- 
quality color 35mm slides or 5-by-7-inch or 8-by-lO-inch 
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author's name, number them sequentially according to their 
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prints. This can damage them. If figures require printing in 
four-color process, the author may be asked to pay printing 
fees or a portion thereof. 

Type figure legends, double-spaced, on a separate sheet 
of paper. Tables should be typed, double-spaced, one to a 
single sheet of paper. All tables must have titles and consecu- 
tive Arabic numbers. Include tables, graphs, or charts on 
disk, if possible. 



Keep references to a minimum (preferably no more than 
15), retaining those that document important points. The 
"Uniform Requirements" cited above contain reference for- 
mat. We customarily list the first three authors for "et al"- 
type references. Authors are responsible for the accuracy 
and pertinence of all citations. 

Avoid abbreviations entirely if possible; keep them to a 
minimum if not. When used, completely define abbreviations 
at the first point of usage in the text. 



Manuscript Review and Editing 

A medically qualified editor reads all manuscripts and, in 
most instances, sends them out for further review by one or 
more other members of the North Carolina Medical Society. 
Authors' cover letters must include a line that states that 
their submitted manuscripts are not under consideration for 
publication elsewhere. Decisions to publish or not are made 
by the editors, advised by the peer reviewers. 

We encourage a relatively informal writing style since 
we believe this improves communication. Imagine yourself 
talking with your unseen audience — as long as this doesn't 
lead you to scientific or linguistic inaccuracy. Be brief, clear, 
simple, and precise. 

We edit accepted manuscripts for clarity, style, and 
conciseness. Except for letters, authors receive a copy of the 
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Authors retain copyright to articles published in the 
North Carolina Medical Journal, but the North Carolina 
Medical Society copyrights the contents of each entire issue. 
Requests for permission to reprint all or any part of a 
published article must be submitted in writing to the address 
below and negotiated with the author and editor jointly. 
Reprinted material must carry a credit line identifying that it 
appeared in the North Carolina Medical Journal. 



Submissions 

Editor, North Carolina Medicaljournal 
Box 3910, DUMC, Durham, NC 27710 
Telephone 9191286-6410, Fax 9191286-9219 
E-mail: yohn0001@mc.duke.edu 



200 



NCMJ July/August 1996, Volume 57 Number 4 



A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

Our Brothers' Keepers 

A History of the North Carolina Physicians Health Program 

Jonnie H. McLeod, MD 



The drama of the development of the North Carohna Physicians 
Health Program lies not in dates or events but in a philosophical 
struggle within the medical community. For years the plot was 
to "get tough" on any physician with any impairment. The very 
idea that the North Carolina Board of Medical Examiners (now 
the North Carolina Medical Board or NCMB) should adopt a 
philosophy of helping was almost heresy to physicians. It took 
years to convince North Carolina doctors that impaired physi- 
cians could heal and reenter practice, healthy and productive. 
The successful program that exists today owes its existence to 
a few determined physicians, some but certainly not all of 
whom I will mention in this article. 



wife, Gail, with support from the NCMS Medical Auxiliary 
(now Alliance), played a significant role in responding to cries 
for help by way of a telephone set up in the Clark home. 

PHEC was a strictly volunteer program for the next decade. 
When a physician's name was reported, Dr. Clark sent that 
person a letter and two members from the Committee visited as 
a personal intervention. Then, a Committee member from the 
appropriate geographical location was assigned to monitor the 
physician. (Later it was suggested that only physicians trained 
in intervention should be members of the Committee.) During 
this 10-year period, about 158 physicians participated in the 
program. The committee's budget was a meager $5,000 a year! 



The Need to Help 

During the 1970s the American Medical Association (AMA) 
became increasingly interested in problems of impaired physi- 
cians. AMA conferences on the impaired physician in 1 975 and 
1977 sparked interest in the North Carolina Medical Society 
(NCMS), much to the delight of the physicians who were 
ab-eady working to gain recognition of the need for an impair- 
ment program. Dr. Phillip Nelson, chair of the NCMS Mental 
Health Committee, appointed an ad hoc committee with Dr. 
Robert Gibson as chair. The committee sought an appropriate 
name for itself that would indicate a comprehensive, preventive 
approach to the health of the physicians and their families. Dr. 
Gibson suggested that it be called PHEC (Physicians Health 
and Effectiveness Committee) as something of a takeoff on 
AHEC (Area Health Education Center). The name stuck. 

The following year PHEC was formally established with 
Dr. Ted Clark as chair. Dr. Clark was one of the early advocates 
of an organized method for helping impaired physicians. Be- 
cause he practiced in an established treatment center, he was 
called on often, especially by distraught spouses. In fact, his 



Dr. McLeod is a pediatrician at 1504 Biltmore Drive, Charlotte 
28207, and a member of the North Carolina Medical Society's 
Physicians Health Committee. 



The Start of a Formal Program 

In 1 985 , the Medical Society assigned a staff member, James P. 
Hughes, part-time to the Committee. Shortly thereafter Alan T. 
McKenzie, then NCMS executive assistant of communica- 
tions, took over that position, and played a significant part in the 
development of the program into its present form. 

By 1986, there was interest in having a full-time medical 
director for an expanded program. The PHEC prepared a 
resolution to be introduced in the House of Delegates. Coinci- 
denlally, the Aging Committee, of which Dr. Jonnie McLeod 
was a member, had become concerned about impairmentcaused 
by aging. The Aging Committee agreed with Dr. McLeod that 
resolutions from both committees should be introduced simul- 
taneously in the House. After consolidation in a Reference 
Committee, these resolutions were jointly returned to the floor 
for debate, during which both strong opposition and strong 
support were manifest. In an unprecedented move. Dr. John 
Foust, president of the NCMS, excused himself as Chair of the 
House and retired to the floor to speak in favor of the action 
item. Dr. John Fagg, Speaker of the House, called for a voice 
vote, and hearing loud nays, ruled the motion defeated. Dr. 
McLeod requested a show of hands vote, which resulted in the 
passage of the resolution. 

Dr. Harold Godwin, a member of the NCMB and long a 



NCM J July I A ugust 1 996, Volume 5 7 Number 4 201 



supporter of the plan for a full-time medical director and 
program, had been stimulated by a lecture in 1986 to the 
Fayetteville Medical Society by Dr. Dave Canavan, founder of 
the first such state program in New Jersey. Dr. Godwin pub- 
lished a commentary in the Journal^ which advocated help first 
and discipline second for impaired physicians. This was a 
crucial time, and without the support of Dr. Godwin, Dr. 
Nicholas Stratas, and Dr. Charles Duckett on the NCMB, 
nothing would have ever developed. For the most part, the 
NCMB had viewed the PHEC as a bunch of "softies." 

During 1985-1987, the NCMS had prepared a piece of 
legislation regarding peer review for submission to the 1987 
NC General Assembly. Alan McKenzie and Bo Bobbitt, then 
legal counsel for the NCMS, added a section to the bill that 
would permit the NCMB, under contract with the NCMS, to 
carry out peer review activities. It would also grant legislative 
immunity to those persons involved in the peer review process. 
In summer 1987, Senate Bill 204, an amendment to the Medical 
Practice Act, was passed. The final legislafion was designated 
SS 90-21.22. 

In 1987, Dr. Wilmer Betts succeeded Dr. Clark as PHEC 
chair. A task force of repre- ^^^^^_^^^^^ 



sentatives (Drs. Betts, Duckett, 
Godwin, McLeod, Stratas, 
Martin Brooks, and Charles 
Vernon) from the NCMS, 
PHEP, and the NCMB began 
work to establish rules and 
regulations for the program, 
following an initial format de- 
veloped by Dr. Betts and Mr. 
McKenzie. Drs. Godwin, 
Stratas, and Duckett from the 

NCMB were vigorously supporfive, and Bryant Paris, execu- 
tive secretary of the NCMB, was a skillful shepherd as the task 
force labored to establish rules and regulations for the forth- 
coming Physicians Health and Effectiveness Program (PHEP), 
as well as working out a Memorandum of Understanding 
between the NCMS and the NCMB regarding the program's 
sphere of operation. In their search for a medical director for the 
new program, the task force reviewed the applications of 36 
people, resulting in the Board's recommendaion that Dr. Robert 
C. Vanderberry be hired. On December 1 , 1988, 23 cases from 
the PHEC were handed over for monitoring, and Dr. Vanderberry 
was given a S 140,000 budget for operafion of the PHEP in 1 989. 
The NCMB has generously supported the program since its 
inception and continues to provide a major portion of its 
funding. To the great credit of Lynn Anderson, a long-time staff 
member, a program of voluntary contributions to the NCPHP 
has developed. These come primarily from individual hospital 
members of the North Carolina Hospital Assoc iafion, the Medi- 
cal Mutual Insurance Company, and the NCMS. The strong 
financial support of these institutions has made possible the 
continued growth of the program and its exemplary record of 
service to its constituency. 



". . .a large fraction of the medical 

community still insists that impaired 

physicians ought to be punished rather 

than helped to recover. Those of us 

who have seen the results know that 

despite the years of struggle, this 

program is more than worth it." 



The Present and the Future 

The PHEP has grown tremendously under the leadership of Dr. 
Vanderberry and his skillful staff, with the strong support of the 
Board and its chairs. Dr. Robert Fleury (from 1992-1994) and 
Dr. Betts (since 1994). But by 1993 it became evident that the 
program could better function in its advocacy role if it were an 
autonomous and indejxindent entity, less closely bound to its 
primary funding sources. This change was accomplished through 
a new Memorandum of Understanding dated November 10, 
1993. The program gained non-profit, tax-exempt status in 
December 1994, and also changed its name to the North 
Carolina Physicians Health Program, a name more concise and 
more consistent with other states. 

The need for secure, ongoing financial support that would 
allow even greater service in the future, and the need to look at 
present and long-term goals prompted the NCPHP Board of 
Directors to move into extensive strategic planning (see article 
on page 243). The Board now seeks support from physician- 
donors, particularly alumni/alumnae of the Program, in an 
annual giving campaign. Perhaps later a capital campaign with 

an endowment can be estab- 
lished. 

It is important for Jour- 
nal readers to know that once 
a physician is reported to the 
Board because of substance 
abuse, sexual abuse, dual di- 
agnosis, or some other impair- 
ment. Dr. Vanderberry makes 
an intervention and sets a con- 
tract,but the physician's name 
remains anonymous, even 
from the Board's Compliance Committee, unless the contract is 
broken. Then the NCMB must be informed. Knowing how the 
process works may make it less difficult to report a colleague 
whose behavior is impaired. Such a report could make the 
positive difference in whether a practicing physician's career 
continues (see articles on pages 204 and 208). 

NCPHP has now grown to the point that more than 600 
professionals (including 29 physician assistants; see related 
article on page 233) have participated. It operates on a yearly 
budget of $608,000. The scorecard for the program shows that 
70% of participants have recovered after the first treatment, an 
additional 18% after a relapse, and 4% retired in good standing. 
Overall that is a 92% recovery rate for physicians (and usually 
for their families). A remarkable record! Even so, a large 
fraction of the medical community still insists that impaired 
physicians ought to be punished rather than helped to recover. 
Those of us who have seen the results know that despite the 
years of struggle, this program is more than worth it. □ 

Reference 

1 Godwin HL. Physician's forum: policing the practice of medicine 
(commentary). NC Med J 1987;48:89. 



202 



NCMJ July/August 1996. Volume 57 Number 4 



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A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

The Riddle of the 

Chemically Dependent Physician 

Heartbreak or Joy? 

Anonymous 

/ missed my daughter's recital because I was in a blackout. 

I missed my oldest son's high school graduation because I was in a blackout. 

I joined a group of Redskin fans on the Streamline Limited to Washington — / didn't get to the game. 
In fact, I didn't even get off the train until I got back home because I was in a blackout. 

I missed President Carter's inauguration despite my VIP invitation because I was in a blackout. 



Had I been asked on any of these occasions, "Are you an 
alcoholic?" I would have answered with a resounding, "No, get 
real man!" And the lie-detector needle wouldn't have wiggled 
one iota, because I would have been telling the truth according 
to my knowledge and my understanding at that time. (Pardon 
me, if I ignore Montaigne's warning that one seldom speaks of 
one's self without some detriment to the person spoken of! 
There are some things that are too important not to share, 
especially when a life is at stake.) 

Let me to draw a parallel by paraphrasing Sir Winston 
Churchill: The chemically dependent human, and especially 
the chemically dependent physician, is a riddle wrapped in a 
mystery inside an enigma. I speak of the chemically dependent 
human being (I use "chemical dependency" and "alcoholism" 
interchangeably in this paper) rather than the chemically depen- 
dent physician, or lawyer, or preacher, or housewife because 
any chemically dependent person is first and foremost a human 
being afflicted with the faults of human nature. Help for the 
chemically dependent person begins only when that person 
comes to understand and accept this reality about their condi- 
tion: 

alcohol + me = my alcoholism 
my alcoholism - alcohol = me! 



The author, a North Carolina Medical Society physician mem- 
ber, in keeping with AA tradition, wishes to remain anonymous. 



Resisting Reality 

The great tragedy of my life (perhaps yours) is how much I had 
to suffer before I learned the simple truths by which I could live. 
If you are an alcoholic like I was and am, you could go to your 
grave without knowing what's wrong with you. One of the most 
dastardly symptoms of this disease of chemical dependency is 
your own mind telling you: "You haven't got it." 

You may remember Lincoln's famous statement that you 
can ' t fool all of the people all the time. That doesn ' t hold for the 
chemically dependent individual. You can fool yourself until 
your heart's content all of the time. When you reach this tragic 
state of mind-blindness, you cannot recognize the truth even 
though it stares you in the face; you do not have a supreme 
command of the obvious! Many of us practice fraud upon our 
own souls. 

Of all forms of deception, self-deception is the most 
deadly; of all deceived persons, the self-deceived are least 
likely to discover the fraud. The reason is simple: when a person 
is deceived by another, they are deceived against their will, they 
are the [temporary] victim of another's guile. If they expect 
their foe to take advantage of them, they are watchful and quick 
to suspect trickery. But self-deceived individuals are their own 
enemies and work the fraud upon themselves. They want to 
believe their own lies and are psychologically conditioned to do 
so (this is called denial). They do not resist deceit but collabo- 
rate with it against themselves. There is no struggle because 



204 



NCMJ July/ August 1996, Volume 57 Number 4 



victims surrender before the fight begins, as though they enjoy 
being deceived. As Pogo said, "We have met the enemy and 
they are us." 

Two primary factors determine my alcoholism: "me" and 
"alcohol." The major difference between my untreated alco- 
holic condition and my general human condition was the 
repedtive and ever-worsening destructive thinking, feeling, 
and action of my untreated alcoholic self. Self-conceit, 
self-deceit, and self-delusion reached pathologic proportions as 
they do in all chemical dependencies and addiction. 

Dependency on alcohol and other drugs swallows up our 
individual differences until we all become ultimately alike in 
the universally similar profile of dependency produced by 
addiction. The addictive life is a "dis-eased" life, but the good 
news is we can all recover. It makes little difference whether we 
drink our boozes or chew our boozes. 



Help for the Chemically Dependent 

The wisdom of the most successful behavior modification 
therapy for the chemically dependent person (the way of life 
espoused in the 12 steps of Alcoholics Anonymous) is simple 
but profound. It takes the full view of the human condition and 
applies that vision to the chemically dependent person. The 
biggest problem in accepting this is not that chemically depen- 
dent persons think they are worms or that they are very special; 
the problem is that they think they are very special worms! This 
hidden sense of uniqueness proves calamitous too often. 

Now, dear friends and colleagues, I didn't come to realize 
these things until I had gotten physically sober and stayed 
physically sober for some time. Not drinking and not drugging 
is an essential part of recovery from the disease of chemical 
dependency, and stopping getting drunk is due 100% to not 
drinking. Now, I don't mean to say that sobriety means recov- 
ery, only that it makes recovery possible. Being in the swim- 
ming pool doesn't mean you're swimming, but it makes swim- 
ming possible. 

My use of alcohol was, in the beginning, self-determined: 
I chose to drink alcohol (although 1 did not choose alcoholism). 
Ah, I hear you say, "You're just splitting hairs, you're getting 
all mixed up in semantics. Why that litUe old suffix '-ism'? 
What difference does that make?" Well, friends, that little old 
suffix is responsible for two things: 

1. It makes alcohol lethal in my life, makes it a deadly poison 
tome. 

2. Just getting a handle on the '-ism' has given me hope — the 
only hope I will ever have of being happy, joyous, and free. 

Biology may dictate our destiny, but only if we allow it to 
do so. Genetics (that is, my heredity) may determine the nature 
of the interaction between me and alcohol, but / determine the 
extent of interaction by drinking — chromosome #1 1 , and Loci 
22 and 23 notwithstanding. Alcohol was the one, the only, the 
necessary and sufficient agent required to make me an alco- 
holic. The road to my alcoholism was paved with booze. 



When chemically dependent persons recover ("get well," 
"have the disease arrested") they develop a much keener 
appreciation of the prophetic admonition: "Behold, I set before 
you the way of life and the way of death" (Jeremiah 21:8). 
Please let us keep in mind always, it is very difficult to recover 
from death! Some people think that I have gone overboard on 
physical sobriety. Alcoholics Anonymous (AA) fellowship, 
and the A A program. I haven't. How can I be "overboard" about 
something that saved my life? 

Sir William Osier, one of the giants of modem medicine, 
said "It is much more important to know what sort of patient has 
a disease than what sort of disease the patient has." Alcoholics 
Anonymous reminds us ". . .but many [alcoholics] do recover if 
they have the capacity to be honest." Both quotations empha- 
size the dominant role of the patient in treatment and eventual 
outcome, regardless of the disease process or the kind of 
treatment used. Honesty allows one to identify the problem of 
chemical dependency, and honesty (rigorous self-honesty) to 
identify the soludon. 

I want to make it clear that I did not suddenly gain insight 
into my illness and decide to learn to live sober. Spontaneous 
insight and alcoholism are incompatible! One of the chief 
symptoms of the illness is that your own mind tells you that you 
don't have it. In the six months prior to being guided into AA, 
I was admitted eight times to psychiau^ic hospitals and institu- 
tions. Three of these admissions were involuntary commit- 
ments. The people who executed these involuntary commit- 
ments knew little or nothing about alcoholism or AA, but they 
knew how to love. 

In Dr. Bob Smith's last major speech to AA he said, "There 
are a couple of things which come to mind which we might lay 
a little emphasis on. One is the utter simplicity of our program, 
so let's not louse it up with Freudian complexes and things 
which might be of interest to the scientific mind but have very 
litOe to do with our actual work; and the other thing is, when the 
12 steps of AA are simmered down to the last, they resolve 
themselves into two words, love and service, we all know what 
love is and we all know what service is — so let's bear these two 
things in mind." 

A tremendous medicine has too often been overlooked: 
love and service, motivated by compassion. I wonder where 
people like the late entertainers Freddie Prinz, James Dean, 
Marilyn Monroe, Elvis Presley, Hank Williams, Judy Garland, 
William Holden, and a host of others might be if someone had 
recognized their self-destructive course, and loved them enough 
to bring them to a program tailor-made for their needs, and 
helped them seek redirection in their lives! I would say the only 
hopeless alcoholic is one whom nobody loves. So long as 
people have friends who love them and whom they love, they 
will live, because to love is to live. Even the love of a dog will 
keep people alive. But let that go, the contact with life go, and 
the "energy of life" fails. 

Bernard Smith said when he retired as chairman of the 
General Service Board in 1 956 : "It struck me, as a non-alcoholic, 
that AA was a 'way of life' for me and for countless others like 



NCMJ July I August 1996, Volume 57 Number 4 



205 



me who had never sought escape in the bottle. The still-drinking 
alcoholic has no monopoly on unhappiness or on the feeling that 
life lacks purpose and fulfillment. In all the years since my first 
meeting with Bill Wilson, I have never lost my initial awareness 
that AA is more than a fellowship for recovering alcoholics, that 
it is indeed a way of life for all who have lost their way in a 
troubled world." 



Hitting Bottom 

One of the greatest events in my life up until now is not my 
victory over alcohol but the completeness of my defeat. Only 
when I was beaten to my knees did! seek the help that could save 
me. My self-will was broken, but a broken will is a rare 
endowment to the school of recovery. We "break" a mule in 
order to teach it and use it. God can take the mistaken, egotistical 
"good" drives of a person and slowly refine them until they 
become of great use to Him and to humanity. With many, God's 
impact is sudden, but with me His work has been lingering, 
slow, and sweet. 

I have heard it said that one should be grateful if the cross 
of life is the cross of alcoholism, of chemical dependency, 
because so many people are ready, willing, and able to help one 
carry it. Nobody recovers from alcoholism without grace from 
two sources — the grace of God and the grace of people. 

Every day I live I become more and more convinced that 
AA's 12 steps represent the finest formula ever conceived to 



help the alcoholic find the way back from the human junk pile 
to a happy, useful, whole life; to convert one's existence from 
a human wasteland to a life of fascination, inspiration, aspira- 
tion, and co-creation. 

I came to AA as a crying and bloody casualty of an unequal 
fight. I was whipped and I knew it. I gave not a twit who else 
knew it. I unconditionally surrendered to the lash of alcohol and 
was given the conscious gift of desperation. This was my 
motivation, my key to willingness. I was willing to listen, 
willing to learn without debating and fighting back, willing to 
trust people for whom the problem had been solved, willing to 
be changed! 

The unconditional surrender forced at the hands of John 
Barleycorn was involuntary on my part. I had no other choice, 
but even in recovery, I must watch for the persistence of 
childishness, immature grandiosity, and infantile defiance. 
When Frank Lloyd Wright was asked how he handled the 
accolades that were constantly being given him, he said: "I had 
to come to terms a long time ago with honest arrogance or 
hypocritical humility." Neither honest arrogance nor hypocriti- 
cal humility has any place in the recovered life of the chemically 
dependent. For if the AA way of life has a heart, it is humility, 
honest humility. 

1, the author of this article, must choose and you cannot 
help me. You, the reader of this article must choose and I cannot 
help you. The choice is mine; the choice is yours. The choice is 
exclusively mine; the choice is exclusively yours. God help 
writer and reader to choose right. □ 




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206 




.^m 



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HEALING HAND FOR PHYSICIAN IMPAIRMENT 



A Case of Professional 
Sexual Misconduct 



Anonymous 



Physicians who commit sexual misconduct must be able to get 
help. These physicians are impaired. Treatment for profes- 
sional sexual misconduct exists and can be effective. Close 
attention to the described sexual misbehavior and its anteced- 
ents enables designated observers to recognize early behavior 
well before sexual acting-out occurs. This can ensure the safety 
of patients, staff, and the physician. Nevertheless, questions 
remain: Can physicians who have been treated for professional 
sexual misconduct return safely to the practice of medicine 
without risking further harmful incidents to patients? In this 
paper I discuss the development of a safe practice plan for a 
psychiatrist (myself) who had sexual contact with female 
patients and female staff. 

It is widely recognized that sexual contact between physi- 
cians (or other health care professionals) and their patients is 
unethical, harmful, and cannot be undertaken with full consent 
(on the part of the patient).'"* Such contact is banned because it 
is likely to harm the patient's care and the patient. Ninety 
percent of patients subjected to such abuse have had some harm 
done.' 

Boundary violations occur when a physician places his 
desires above the patient's needs. Similar violations occur in 
relationships involving employees, students, and supervisees.* 
An ethical "gray area" exists, unfortunately, in regard to rela- 
tionships "^'wh former patients. Separate surveys indicate that 
30% of psychiatrists and 35% of psychologists feel that inti- 
mate contact is acceptable after termination of therapy .*■' Be- 
cause there is uncertainty, the absolute prohibition of sexual 
contact with patients during or following treatment has been 
proposed.^ I strongly believe that any and all relationships and 
contact with patients and former patients ought to be prohibited. 



The author of this piece wishes to remain anonymous. Direct 
any questions to the Jouma/ Editor. 



More than 50% of all psychiatrists have treated or will treat 
a patient who at some time was sexually involved with a 
previous therapist.' Several surveys of psychiatrists and thera- 
pists indicate that 5%-13% acknowledge having engaged in 
sexual behavior with their patients. The percentages for other 
medical specialties (ob-gyn, surgery, internists, family prac- 
tice), psychologists, and social workers are comparable.*'*'' The 
psychological impact was the same whether women had sexual 
contact with therapists (including psychiatrists) or with other 
health practitioners (mainly nonpsychiatrists).'" Given that 
such surveys depend on the self-disclosure of unethical behav- 
ior (with its professional and legal repercussions), these data 
must be considered conservative. 



What Leads to Sexual Misbehavior? 

The boundary between professional and unprofessional behav- 
ior is not always distinct, and boundary violations often develop 
long before actual sexual behavior begins. Ninety-six percent 
of male psychiatrists have at some time been sexually attracted 
to a patient." Feelings of affection may be elicited in medicine 
by the caring conversation, and by the listening. Listening to 
others and being concerned about their welfare may, if we are 
less than aware, lead us to misconstrue our feelings as the magic 
aura of love. Professional restraints may falter under a variety 
of influences. Misbehavior is a complex phenomenon, rarely 
caused by a single factor. A number of papers have examined 
and categorized the types of behaviors of physician-offenders. 
I present here a summary of several different schemes of 
classification. Each is unique, but a sense of commonality 
emerges. Probably all contain elements of truth. 

Borys and Pope describe therapists-in-training as unlikely 
to disclose their sexual impulses for fear of being labeled 
"seductive" and advised to change professions.* Ricker and 
Carmen note that residents rarely discuss sexual counter- trans- 
ference feelings during supervision.*''^ Training programs do 
not provide an authentically safe and supportive environment in 



208 



NCMJ July/August 1996, Volume 57 Number 4 



which residents and educators can attend to this issue. Butler 
and Zelen reported that most professional offenders could not 
recall the actual events that led to erotic contact, but 90% said 
they were "vulnerable, needy, and lonely," with unsatisfying or 
disintegrating personal relationships. '^ The profile emerges of 
a middle-aged therapist, most commonly a man, professionally 
isolated, undergoing personal difficulties that trigger a longing 
for nurturance, and tending to overvalue his healing capacity. 
Male offenders tend to be disillusioned with the workplace and 
to feel anger toward the institution in which they work." 

Therapists involved in sexual misconduct tend to be sig- 
nificantly older than the patients. Interestingly, psychiatrists 
who had themselves been through personal therapy were more 
likely to become sexually involved with patients. Professionals 
who engage in sexual misconduct make infrequent use of 
consultations, and the only distinguishable difference between 
one-time offenders and repeat offenders is an even lower use of 
consultation by the repeat offenders.* Dreiblatt identified other 
risk behaviors: focusing practice on highly vulnerable clientele, 
unusual office practices (late hours, etc.), practicing when 
impaired, and becoming too narcissistic (taking one's impor- 
tance to patients too seri- 
ously).'" 

Bory s and Pope report that 
private practitioners (solo or 
group) tended to engage in in- 
cidental involvement (accept- 
ing a patient's invitation to a 
special occasion) with a sig- 
nificantly greater number of 
patients than practitioners in 

other settings. Respondents who live and work in a small town 
report engaging in social involvements (friendship, sexual 
activity after termination of psychotherapy, hiring a client) 
more often than practitioners who live in one town and work in 
another.' 

In Out of the Shadows, Games compares compulsive 
sexual behavior to alcoholism or other chemical dependencies. 
He classified a wide range of individuals into the single cat- 
egory of sexual addiction, and maintained that sex addiction is 
characterized by symptoms typical of other forms of addiction: 
an inability to stop the behavior even in the face of serious 
consequences, and feelings of despair that follow the compul- 
sive behavior but then lead back to ritualized repetition of the 
behavior for relief 

Irons has a more complex (and poetical) formulation that 
relates the sexual misbehavior to an attempt to cope with inner 
wounds. He has identified several prototypes that characterize 
offenders: 

• the naive prince (a professional in early career who feels 
invulnerable, develops "sj)ecial relationships" with certain types 
of clients, and blurs boundaries); 

• the wounded warrior (a person overwhelmed by demands, 
overly dependent on the professional mantle for validation, for 
whom patient involvement provides temporary escape); 



• the 5e//-5e/-v/Vii' marry'' (^individual in middle or late career, 
for whom work has become primary; tends to be withdrawn, 
angry, and resentful); 

• iha false lover (an individual who enjoys living on the edge, 
a risk-taker who desires adventure); 

• the dark king (a powerful and charming individual, success- 
ful, manipulative; uses sexual exploitation as an expression of 
power); and 

• the wild card (a person who has followed an erratic course in 
personal and professional life; significant difficulties in func- 
tioning, has character disorder)."" 

Schoener and Gonsiorek classified offenders based on 
character types: 

• uninformed and naive (a person who has difficulty under- 
standing and operating within professional boundaries); 

• healthy or mildly neurotic (the improper behavior usually 
represents an isolated or limited episode; these individuals are 
remorseful, terminate inappropriate behavior on own, some- 
times self-report); 

• severely neurotic and/or socially isolated (these persons 
have long-standing emotional problems, depression, feelings 

of inadequacy, low self-es- 
teem, and social isolation. 
Work is the center of life and 
personal needs are met through 
work. They foster inappropri- 
ate closeness with patients 
during and outside the office 
and confuse personal and pro- 
fessional boundaries. They 
may experience guilt and re- 
morse, but are unlikely to terminate the inappropriate behavior. 
Guilt leads to self-punitive behavior rather than constructive 
change. Denial and distortion mask the inappropriate sexual 
quality of the behavior); 

• impulsive character disorder (individuals with long-stand- 
ing problems of impulse control in most areas of their lives; 
poor judgment, little remorse or awareness of harm to the 
victim); 

• sociopathic or narcissistic character disorder (these profes- 
sionals carry out calculating and deliberate abuse of patients; 
manipulative); and 

• psychotic or borderline personality (severely disturbed indi- 
viduals with impaired reality testing, poor social judgment)." 



The Antecedents of 
My Sexual Misconduct 

As an illustration of the antecedents to professional sexual 
misconduct, my history is illuminating. During my psychiatry 
residency 1 was reluctant to discuss my own sexual impulses 
toward patients (counter-transference) for fear of being seen as 
seductive or exploitative. 1 was already experiencing personal 
turmoil — a marital separation and separation from my children 



"The profile emerges of a middle-aged 

therapist, most commonly a mar^, 

professionally isolated, undergoing 

personal difficulties that trigger a 

longing for nurturance. , , ," 



NCMJ July/August 1996, Volume 57 Number 4 209 



led to depression, feelings of inadequacy, anger, and "power- 
lessness." I was drinking heavily, and was in therapy. It was 
against this background that I became involved with a former 
patient. 1 was just finishing my residency. This woman was six 
years younger and unmarried. The relationship occurred ap- 
proximately six months after termination of therapy and was 
unplanned. I knew that a post-trcauncnt relationship was not 
clearly proper. I kept it hidden. 

After residency I entered solo private practice in a small 
town. In that environment boundaries were easily blurred, 
patients were also the providers of services, we employed 
patient's family members, I provided therapy to social friends 
or to employees at the hospital. Once again, I became involved 
with another former patient. Several months after treatment 
ended, she moved to the town where I practiced. I hired her as 
a secretary in my office and eventually a sexual relationship 
began. I told myself that post-u-eatment relationships were not, 
per se, unethical, but I kept our relationship hidden, and felt 
guilt and shame. The relationship drifted: she found new 
romantic interests and left the position. My own personal and 
professional life improved and I felt more secure profession- 
ally. 

Within a few years I was 
experiencing more disu^ess — 
a protracted lawsuit regarding 
a fraudulent investment, and a 
struggle (in which I felt pow- 
erless) over quality of care wi th 
a managementcompany. 1 was 
treating very difficult patients; 
I was professionally isolated. 
Work became my entire focus. 
I was drinking heavily, and I 

overvalued my healing capabilities. I became overinvolved and 
overextended with a female patient. I wanted very much to help 
her and believed that I was the only one who could. I saw her 
often, in long sessions, to try and help her pain from past 
traumas. I lost perspective. In my attempt to show her safe 
caring, I progressed from nonerotic to erotic contact, com- 
pounding the victimization I had sought to help. She became 
terribly frightened and confused by my behavior. I know that I 
caused her a great deal of harm and confusion about trust. 

By this point, work had become the ccnU'al focus in my life. 
I neglected my home life. My second marriage deteriorated. My 
validation came from work, my emotional needs were met there 
from the admiration of the staff, and eventually my sexual needs 
were met there, too. I had an affair with a female coworker. I 
experienced a narcissistic abandonment when that relationship 
ended. I became depressed and hopeless. 

During summer 1993, my drinking escalated to the pointof 
impairment. I was separated from my wife, had onerous debts, 
and filed for bankruptcy. I was in personal therapy for depres- 
sion and for "being out of control." I was disillusioned with 
work and angry with my workplace. I felt burned out, and was 
working with very difficult patients. I became sexually preoc- 



"As I look bock I can see some 

of the antecedents that led to 

boundary blurring. I overvalued my 

healing capabilities, feeling I v^as 

the only one who understood 

these difficult patients." 



cupied, almost obsessed, focusing on attractive young women. 
Over a two-month span, I dated three patients and had sexual 
contact with one. At that point intervention occurred. 

As I look back I can see some of the antecedents that led to 
boundary blurring. I overvalued my healing capabilities, feel- 
ing I was the only one who understood these difficult patients. 
I spent disproportionate amounts of lime with certain patients. 
I kept secrets (I did not chart or share certain information). The 
patients would talk freely with me, but were defensive with 
other staff. I saw them as "my" patients in a possessive way. I 
spent long periods of time with certain female staff, confiding 
in them and relying on them for emotional and personal support. 

My denial and distortion masked the inappropriate sexual 
quality of my behaviors. Typical of my distorted rationaliza- 
tions were the following: "Contact with a former patient is 
permissible." "It was a mutual attraction and decision." "Time 
out" (I pretended that the therapeutic relationship didn't operate 
when contact occurred outside normally scheduled time and 
location).' "I'm not her therapist, only her medication-check 
doctor" (I ignored the difference in power between doctor and 
patient, and violated the bond of trust — that the physician will 

do what is best for the patient). 
- The use of alcohol was part of 
my self-seduction. 



My Treatment 

Little in the current literature 
relates to treatment for profes- 
sional sexual misconduct, and 
there is no study of treatment 
outcome. This is not surpris- 
ing since the rate of relapse appears quite low, and further, it 
would not be ethical to have a control group of sexually 
impaired physicians left untreated for the purpose of study. 
Although the term "sexual addiction" is often used as a descrip- 
tive metaphor for professional sexual misconduct, one should 
not assume that these problems are well addressed in 12-step 
programs.'^ On the other hand, it appears that treatment and 
rehabilitation plans do help, especially when: 1) the practitioner 
admits a modicum of responsibility; 2) the treatment is the first 
intervention for this kind of behavior; 3) having been caught, 
the professional is motivated to change; 4) the professional is 
not overwhelmed by life problems; and 5) the risks of treatment 
are definable and limited.'* 

A program at the Walk-In Counseling Center in Minneapo- 
lis focuses on the assessment and rehabilitation of professionals 
who have sexually misbehaved with their patients. An exten- 
sive description of all misconduct and personal adjustment is 
assembled to develop a hypothesis about the cause(s) of the 
misbehavior. The final rehabilitation plan may include personal 
psychotherapy, practice limitations, and ongoing supervision. 
The plan is very specific as to what will be reviewed, by whom, 
and to what ends.'* 



210 



NCMJ July I August 1996. Volume 57 Number 4 



My personal experience was with the treaimeni program 
begun by Dr. Gene Abel at the Behavioral Medicine Institute of 
Atlanta, which has successfully reintegrated professionals back 
into practice. The major components of treauncnt include 
training in cognitive-behavioral procedures to decrease inap- 
propriate sexual arousal, detailed examination of episodes of 
sexual misconduct in order to identify the antecedents of the 
inappropriate behavior, and education of the physician about 
the impact of sexual misconduct on the victim. To ensure 
compliance with treatment objectives, a detailed plan is devel- 
oped, specifying how future patients will be protected, and a 
surveillance network is established.' 



My Practice Plan 

The purpose of a safe practice plan is to ensure that the physician 
takes the precautions that will enable him to practice in a safe 
manner without misbehaving sexually with either patients or 
staff. As a physician who has been involved with female 
patients, 1 found the safest approach was to work in a setting 
where I would U"eat only male patients, such as a stale hospital 
system, the criminal justice system, or the Veterans Adminis- 
tration system. 

The problem of ensuring safe practice with female staff 
was more difficult. I found it best to fully inform my profes- 
sional and paraprofessional coworkers about the details of my 
prior sexual misconduct with female patients and female staff 
members. I did this by presenting an educational program on 



professional sexual misconduct, sharing my personal history in 
detail, including my typical antecedent behaviors and other 
forms of boundary violation. 

Three professionals who are able to observe me at work 
were selected to act as a supervisory team. During the normal 
course of the day they observe my interactions with patients and 
coworkers. They complete monthly reports on my behavior and 
forward this information to my treatment supervisors. The 
surveillance forms (sample on next page) provide a detailed 
description of the typical behaviors which in the past allowed 
me 10 engage in sexual misconduct, so the team is alerted to 
what behaviors might indicate potential for misconduct These 
surveillance data are reviewed monthly and I get feedback 
about the team's observations. The treatment team investigates 
any report of suspicious or inappropriate behavior. Summaries 
of the surveillance data are forwarded to the North Carolina 
Medical Board. 

This safe practice plan is working. The intervention pro- 
cess by the North Carolina Physicians Health Program and the 
North Carolina Medical Board was the instrument that saved 
this doctor. The fear of exposure had prevented me from 
honestly confronting my dark side. I can say now that I have 
learned as much from my failures and shadows as from my 
successes. I am grateful for a chance to be in recovery. □ 

Acknowledgment: This paper was written with deep gratitude 
to Dr. Gene Abel, his staff at the Behavioral Medical Institute 
of Atlanta, and for the benefit of other impaired physicians 
seeking acceptance and change. 



References 

1 Council on Ethical and Judicial Affairs, American Medical Asso- 
ciation. Sexual misconduct in the practice of medicine. JAMA 
1991;266:2741-5. 

2 American Psychiatric Association. TTie Principles of Medical 
Ethics (with annotations, especially applicable to psychiatry). 
Washington, DC: APA, 1993. 

3 American Psychological Association. Ethical principles of psy- 
chologists and code of conduct. American Psychologist 
1992:1597-1611. 

4 American Association for Marriage and Family Therapy . A AMFT 
Code of Ethics. Washington, DC: AAMFT, 1991. 

5 Borys DS, Pop>e KS. Dual relationships between therapists and 
clients: anational study of psychologists, psychiatrists, and social 
workers. Prof Psychol Res Prac 1989;20:283-93. 

6 Herman JL, Gartrell N, Olarte S, et al. Psychiatrist-patient sexual 
contact: results of a national survey, 11. psychiatrists' auitudes. 
Am J Psychiatry 1987;144:164-9. 

7 Abel GG, Barrett DH, Gardos PS. Sexual misconduct by physi- 
cians. J Med Assn Georgia 1992;81:237^6. 

8 Gartrell N, Herman J, Olarte A. Psychiatrist-patient sexual con- 
tact: results of a national survey, 1. prevalence. Am J Psychiatry 
1986;143:1126-31. 

9 Kardener SH, Fuller M, Mensch IN. A survey of physicians' 
attitudes and practices regarding erotic and nonerotic contact with 



patients. Am J PsychiaUy 1973;130:1077-81. 

10 Feldman-Summers S, Jones G. Psychological impacts of sexual 
contact between therapists or other health care practitioners and 
their clients. J Consult Chn Psychology 1984;52:1054-61. 

1 1 Olarte SW. Characteristics of therapists who become involved in 
sexual boundary violations. Psychiatric Annals 1991;21:657-60. 

1 2 Rieker PP, Carmen E. Teaching value clarification: the example of 
gender and psychotherapy. Am J Psychian-y 1983;140:410-5. 

13 Butler S, Zelen SL. Sexual intimacies between therapists and 
patients. Psychotherapy: Theory, Research, and Practice 1977; 
14:139-45. 

14 Dreiblatt IS. Health care providers and sexual misconduct. Annual 
meeting. Federation of State Licensing Boards, 1991. 

15 Carries P. Out of the Shadows: Understanding Sexual Addiction. 
MinneafX)lis: ComCare Publisher, 1992. 

1 6 Irons R. On seduction and exploitation: a medical model approach. 
Rhode Island Medicine 1994;77:354-6. 

17 Schoener GR. Rehabilitation of Professionals Who Have Sexually 
Touched Clients: Assisting Impaired Psychiatrists, rev. ed. Wash- 
ington, DC: American Psychological Association, 1991. 

18 Schoener GR, Gonsiorek JC. Assessment and development of 
rehabilitation plans for counselors who have sexually exploited 
their clients. J Counseling and Development 1988;67:227-32. 

Continued 



NCMJ July/ August 1996, Volume 57 Number 4 21 1 



Physician's Surveillance Form 



Rater's name: 



Date: 



Rater's signature: 



Dr. has admitted to past inappropriate sexual behavior with adult female patients and 

female staff; having "dated" patients away from work, had sexual contact with them, and had affairs 

with staff/employees. Dr. reports that in the past these inappropriate behaviors may 

have been recognized because he spent excessive time with these patients or staff; developed 
"special" relationships and discussed personal issues with them; he socialized outside the office with 
these female patients and female staff. 



This form is to be completed by staff who work with Dr. 



and/or his patients. Your 



response will not be kept confidential but will be made available to the licensure board, and Dr. 
's therapist. 



Please evaluate each area of performance by circling the appropriate number: 
1= never 2= sometimes 3= often 4= n/a 



1. Seen, or reported to be socializing with female patient or female staff 



2. Evidence or reports that he may have been drinking 



3. Evasive or guarded about woman he is dating 



4. Overly friendly with or touching female staff 



5. Appears exhausted or distracted in behavior at work 



6. Lacks weekly supervision about professional sexual misconduct issues 



2 
2 
2 
2 

2 



3 
3 
3 
3 

3 



4 
4 
4 
4 
4 



If you answer any of the above "sometimes" or "often" please append specific details. 
Please append any specific documentation. 



Dr. 's signature below indicates his awareness and approval ofyoursurveillance of him, 

and he agrees to your advancing these reports to the North Carolina Medical Board irrespective of their 
consequences to him and to his therapist, Dr. . 



Physician's signature 



212 



NCMJ July /August 1996, Volume 57 Number 4 




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A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

Psychiatric Diagnoses in 
North Carolina Physicians 
Health Program Participants 

Wilmer C. Belts, MD 



Since December 1, 1988, North Carolina has had a program to 
intervene with, specify treatment for, and to monitor impaired 
physicians. To date, more than 600 individuals, most with prob- 
lems related to substance abuse, have participated in the North 
Carolina Physicians Health Program (NCPHP). Of the total, 
103 (17%) have carried a psychiatric diagnosis, either as the 
only cause of their impairment or existing together with and 
contributing to substance abuse. NCPHP's main goal has been 
the treatment of chemical -dependent doctors, but in this report 
I point out the very encouraging results of treatment of such 
individuals, both those with a dual diagnosis of substance abuse 
and psychiatric disorder and of those with only a psychiau^ic 
disorder. 



Of the 31 participants who carried a dual diagnosis, 16 
(52%) have recovered or are in remission, and have returned to 
active medical practice; five more (16%) have recovered or are 
in remission but have elected to retire. Treatment has failed four 
participants (13%), including one who died from a drug over- 
dose. The outcomes for the remaining six (19%) are not yet 
determined. 



"Individuals with dual diagnoses have 

long been the 'forgotten patients,' 

those who 'slip through the cracks.'" 



Dual Diagnosis 

On February 15, 1996, when the total number of participants in 
the NCPHP stood at 600; 497 (83%) carried a diagnosis of 
substance abuse disorder; 72 ( 1 2%) , a diagnosis of a psychiatric 
disorder; and 3 1 (5%), a dual diagnosis of substance abuse and 
a psychiatric disorder. Table 1 (at right) shows the diagnoses 
and gender distribution of the 31 participants with a dual 
diagnosis. The data are similar to those of Nace et al,' who 
studied physicians admitted toasubstanceabuse unit. Affective 
disorders were present in 96% of physicians with a dual 
diagnosis. 



Dr. Belts is a psychiatrist at 920-A Paverstone Drive, Raleigh 
27615. He chairs the Board of the North Carolina Physicians 
Health Program and is a member of the Medical Society's 
Physicians Health Committee. 



I want to emphasize that a participant's affective disorder 
must be stabilized if effective recovery is to be possible, but I 
make no attempt to decide here whether the substance abuse or 
the affective disorder represents the primary diagnosis. Suffice 
it to say that in most instances a relapse of the affective disorder 



Table 1. Psychiatric diagnoses in 31 of 528 
NCPHP participants with substance abuse 



Diagnosis 


Male 


Female 


Total 


Bipolar disorder 


11 


4 


15(2.8%) 


Major depression 


14 


1 


15(2.8%) 


Dysthymia 


1 





1 (0.2%) 



Total 



26 



31 (100%) 



Note: five each from the bipolar and major depression group are 
not practicing. 



214 



NCMJ July/ August 1996. Volume 57 Number 4 



occurs with or contributes to substance abuse relapse. Over- 
whelmingly disruptive affect leads to substance abuse relapse 
because it impairs both ego function and the ability to use 
previously learned tools of recovery . My admonition to patients 
with affective disorders and substance abuse is: "Take your 
Lithium. Don'ttakeadrink. Go to the [Alcoholics Anonymous] 
meetings." I encourage these patients to accept the idea that they 
arc powerless to control their affect in the same way that 
alcoholics and drug abusers are powerless over alcohol or 
mood-altering drugs. Patients must apply "The Tools of Recov- 
ery" to both their substance abuse problem and their affective 
disorder. 

Individuals with dual diagnoses have long been the "for- 
gotten patients," those who "slip through the cracks." Sub- 
stance abusers whose affective disorder or anxiety disorder 
remains undiagnosed or untreated are at high risk 
for substance abuse relapse. Co-morbid disorders 
must be carefully addressed and appropriately 
treated if we expect a solid recovery and success- 
ful return to medical practice. 

In addition to affective disorders, I predict a 
high incidence of anxiety disorder, especially so- 
cial phobia, among physicians with substance 
abuse. We need to sharpen our diagnostic acumen 
to detect and treat such individuals. I have also 
been impressed by the remarkably large number of 
patients with bipolar disorder I have examined 
personally or whose stories I have heard at AA 
meetings. Many of these individuals have man- 
aged to stay sober in an active AA recovery pro- 
gram in spite of continued cycling of mood, often 
neither formally diagnosed or treated. 



Table 2. Psychiatric diagnoses 




in 72 NCPHP participants 




Diagnosis 


Cases 


Major depression 


33 (46%) 


Antisocial personality disorder 


16(22%) 


Personality disorder (other) 


8(11%) 


Bipolar disorder 


7(10%) 


Schizophrenia 


3 (5%) 


Obsessive-compulsive disorder 


2 (3%) 


Anxiety disorder 


1 (1%) 


Bulimia 


1 (1%) 


Dementia 


1 (1%) 


Total 


72(100%) 



Table 3. Outcome of psychiatric treatment 




in 72 NCPHP participants 






Diagnosis 


Practicing 


Not practicing 


Major depression 


25 


8 


Antisocial personality disorder 


7 


9 


Personality disorder (other) 


6 


2 


Bipolar disorder 


5 


2 


Schizophrenia 





3 


Obsessive-compulsive disorder 


2 





Anxiety disorder 





1 


Bulimia 


1 





Dementia 





1 


Total 


46 


26 



Solitary Psychiatric Diagnoses 



Conclusions 



Of the 600 patients, 72 (12%) had a psychiatric diagnosis but no 
substance abuse diagnosis (Table 2, above). These patients 
were monitored by the NCPHP in collaboration with a treating 
psychiatrist, but these patients are at high risk: two with major 
depression and one with schizophrenia committed suicide, and 
there was one accidental death in a patient with antisocial 
personality. Nevertheless, treatment can be quite beneficial. 
The final outcome, after adequate treatment and monitoring, 
shows that 46 of 72 (64%) physicians impaired because of 
psychiatric disorders have successfully returned to practice 
(Table 3, above). 



The results of treatment of 103 physicians with psychiatric or 
dual psychiatric and substance abuse diagnoses reveals the 
efficacy of appropriate treatment and monitoring. Our results 
clearly show that physicians impaired by psychiatric disorders 
can be appropriately and successfully treated and monitored in 
a program that was begun to treat physicians impaired by 
chemical dependency. Some of those suffering only from 
psychiatric disorders attend 12-step AA meetings along with 
the chemically dependent physicians and find the fellowship 
both congenial and supportive. □ 



Reference 

1 Nace EP, Davis C, Hunter J. A comparison of male and female 



physicians treated for substance abuse and psychiatric disorders. 
Amer J Addictions 1995;14:156-62. 



NCMJ July/ August 1996. Volume 57 Number 4 



215 



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A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

The Contrast Beween Physicians 
Seen by the iVledicai Board and 
Those Seen in Private Practice 



Nicholas E. Stratas, MD, FAPA 



For the past 20 years I have spent much of my professional time 
with physicians, their spouses, and their children. In a way these 
physicians and their families have been my mentors. I have 
watched them and learned from them. Because they are valued 
peers, I try to be open, to stay connected, to provide quality 
service, to stay balanced and resilient when these colleagues 
and their families consult me about their struggles — personal, 
marital, family, and professional. 

I have also served six and a half years on the Board of 
Medical Examiners of the State of North Carolina (now known 
as the North Carolina Medical Board). This has provided 
further stimulating, educational, even mind-boggling experi- 
ence. In contrast to private practice, physicians come before the 
Board on a command performance at the Board's request. I 
recall vividly the long hours of intense exchange with physi- 
cians who were apprehensive, suppressed, defensive, hostile, 
sad, tearful, and always anxious. I want to share with you some 
of the thoughts and ideas that these contrasting professional 
activities have provided. I hope to point out that physicians can 
and do get sick, that they have the right to be patients and to 
receive medical help, and that they can change their ways to 
make fora happier, healthier lifestyle and professional practice. 



The Board Experienced'^ 

Case 1. A 38-year-old family practitioner was invited to appear 
before the Board because he was unable to deal with his 
alcoholism. It had created problems in his medical practice and 
in his second marriage. 



Dr. Stratas is a psychiatrist at 3900 Browning Place #201, 
Raleigh 27609. He is Past President of the North Carolina 
Medical Board and serves on the Medical Society's Physicians 
Health Committee. 



There was a long background. His father and an uncle had 
had problems with alcohol. As a youth, he was good at sports, 
but he found greater rewards in academics. His use of alcohol 
began early and escalated in college where he also began to use 
other drugs, marijuana at first. Despite his drug use, he gradu- 
ated but continued the same behaviors in medical school; he 
was seen briefly in the psychiatric department as result of 
"erratic behavior," spotty grades, and absenteeism. He had an 
impulsive, volatile, and short-lived marriage to an alcoholic 
woman. He completed his residency, married a second time, 
and had two children. The alcoholism continued, and he added 
benzodiazepines. His wife, a nurse, supported him; he gathered 
a large and loyal following of patients with whom he spent long 
hours. 

He was confronted about his use of alcohol when he came 
to the emergency room with alcohol on his breath. He had been 
spending less and less time with his wife (and often under the 
influence). When he did not respond to the hospital when on 
call, he was reported to the Board. He was given a stem warning 
and admonishment, but the pattern continued, resulting in two 
further summons to the Board. Thankfully, by the third visit the 
Physicians Health and Effectiveness Program (now the Physi- 
cians Health Program orNCPHP) was in existence. His license 
was suspended and a contract was developed with NCPHP 
which included"90 meetings [of Alcoholics Anonymous] in 90 
days," a thorough medical and psychiatric evaluation, and 
appropriate treatment (with reports to NCPHP and the Board, 
and random urine drug testing). He and his wife were counseled 
about co-dependence. 

He returned to the next Board meeting remorseful and 
grateful. Because he had implemented the contract, he was 
given a three-month license. He is now back practicing in a 
structured setting and continues his recovery program. In addi- 
tion to his alcoholism and drug abuse problems, he was found 
to have major depression and dysthymia (a long-term 
depressiveness). He is in psychotherapy, and takes fluoxetine 



218 



NCMJ Julyl August 1996, Volume 57 Number 4 



and trazodone. He is active in Alcoholics Anonymous and the 
Caduceus Group. 

Case 2. A 62-year-old general practitioner was called before the 
Board after one of its investigators, during a routine check of the 
physician's pharmacy, found a large number of controlled 
substances ostensibly prescribed by him for multiple patients. 
The investigator took his findings to the physician for clarifica- 
tion. At the office he was met by a roomful of patients and a staff 
person, who was rude and abrasive. When the investigator 
asked for a more convenient appointment, he was told there 
were none and he would just have to wait his "turn" like 
everybody else. An hour later he was placed in an examining 
room where he waited another 20 minutes. 

The doctor was friendly and cordial. The investigator 
introduced himself and asked some questions about the prac- 
tice, the kinds of patients seen, and the doctor's prescribing 
habits. The doctor became increasingly defensive, then sarcas- 
tic and belligerent. The investigator left. Following his report to 
the Board, copies of the patient charts in question were subpoe- 
naed for review by Board members. The doctor couldn't make 
the first date he was asked to appear; when he did come he was 
a neat, somewhat harried-looking man carrying a box of charts. 
His responses to questions were curt and monosyllabic. As each 
patient chart was reviewed, he became increasingly flustered by 
the fact that he had failed to document his own practices, by the 
absence of supporting data for prescriptions issued, by the 
scanty or absent objective data and labwork, and by absence of 
consultations. Moreover, most of his notes were illegible. 

He was seeing 40-50 patients a day, of all ages and both 
sexes. He did little hospital work. He was married to a nurse who 
had once been supportive, and even now occasionally helped 
out at the office. Their relationship had shifted from one of 
mutual support to veiled hostility. They had three grown chil- 
dren, two of whom were having their own problems. He was 
warned by the Board to examine his professional behavior, to 
write legibly, and to return in six months. 

On return, there had been no changes. He was asked to 
relinquish his license for controlled medications and to dictate 
his notes using an accepted, standardized format. The Board 
considered (but did not have him take) a competency examina- 
tion. No formal charges were filed against him. Two months 
later, his records were typed using the SOAP format. He had 
begun to refer pain patients to other doctors for care or for 
consultation (a number of patients had simply left him when 
they learned he could no longer prescribe controlled sub- 
stances; he was relieved). His records contained supporting 
data and he was using antidepressant medications for many of 
his anxious and sleep-disturbed patients with good results. He 
had attended a workshop on "the chronic patient." He had a 
decidedly different attitude about his past practices. He was 
grateful that the Board had intervened without removing his 
license to practice. He had cut back on his hours, was seeing 
fewer patients a day, and had even taken a long weekend off 
with his wife! 



My Private Practice Experience 

In private practice, physicians seek help on their own, without 
Board interference. They seem to be a different group. They 
present earlier and have a level of insight' 

Case 1. A 52-year-old radiologist called me to say that he felt 
irritable and had been told that he was by his wife and col- 
leagues. He did not want to jeopardize his marriage or his 
practice. When he came for initial evaluation, he was a tall, 
well-developed, and clearly concerned man. He reviewed his 
"good upbringing," his hard-working, businessman father who 
did things with him but who was emotionally distant, and a 
"typical mother" who "was always there for us." He had three 
siblings, each successful, each married with children. 

He had always been good at whatever he had tried, but his 
life was out of balance. He took no time for relaxation, medita- 
tion, prayer, introspection, or centering. He did not exercise. He 
had an intense desire to "do things right." He was committed to 
continuing education and his family vacations were always 
planned around workshops and meetings. He had occupied 
positions of responsibility in various medical organizations. 

At the second session, as is my custom, I asked his wife to 
come with him. She reaffirmed his irritability and said he was 
"no fun anymore." She talked about the significant, but gradual, 
decrease in their intimacy over a pehod of years. He agreed. 
After establishing a contract and treatment goals, I explained 
relaxation procedures and other behavioral techniques to in- 
crease his awareness of himself and his feelings. 

It became clear that he had learned to get his rewards 
through achievement at school. Moreover, he was "the man in 
the family" to whom his mother turned; he had acquired a sense 
of responsibility for the family members. That pattern persisted 
with his current family and his patients. He learned to recognize 
his lack of intimacy and the emotional distancing from his wife. 
He came to understand why he always wanted to "get things 
right" and have things "his" way. 

His wife was depressed and we treated this. His two 
children were also involved in the treatment. They were able to 
clarify their goals, and what they needed from each of their 
parents. Fortunately, they had no significant problems and went 
on to experience success in college. 

The doctor and his wife now enjoy a much closer relation- 
ship. They have made it clear that each is responsible for his or 
her own well-being and growth, and that both need to work with 
and invest in each other. They schedule regular exercise and 
relaxation, use centering techniques, and have reaffirmed their 
commitment to their spiritual growth. 

My diagnosis was "adjustment disorder with marital dys- 
function and underlying personality patterns of obses- 
si ve-compulsiveness, narcissism, and dependence." Treatment 
consisted of individual therapy using psychodynamic and cog- 
nitive-behavioral methods, and early involvement of his wife in 
family systems work. 



NCMJ July/August 1996. Volume 57 Number 4 21 9 



Case 2. A 45-year-oId married internist disclosed a long-lasting 
and ongoing lack of pleasure. He would periodically give 
himself a pep talk or scold himself, after which he "got it 
together" and did better for a while before gradually slipping 
"into the doldrums again." He had slept lightly and fitfully for 
a long time for which his primary physician periodically pre- 
scribed temazepam. He was able to do essential tasks, but had 
no energy for anything else. He thought he could not focus or 
concentrate as well as in the past. He had no history of depres- 
sive, manic, or hypomanic episodes. There was no substance 
abuse, but he was an amateur wine collector and lately he and 
his wife had been drinking increased amounts each evening 
with dinner. He admitted to a flirtation with a nurse which he 
said made him feel "better," and he wondered if he had married 
the "wrong woman." 

In the conjoint session his wife identified what she thought 
was a long-term depressiveness in him. She had been active in 
the Medical Auxiliary (now the Alliance) and other organiza- 
tions to support her husband but did not feel appreciated by him. 
She was an elementary school teacher but had not worked since 
the birth of their daughter. She was concerned that he was not 
spending "quality time" with their one child. Both described a 
"lack of communication" and felt they were simply "going 
through the paces." There were periodic outbursts of angry 
yelling at each other. 

His father had been a hard-working pharmacist, but was 
not close to the patient. His mother had taught school intermit- 
tently, before and between pregnancies and after the children 
reached school age. The doctor was the second of four children. 
Ail had some college education and his brother, divorced, was 
a surgeon in Maryland. His younger sister was in a second 
marriage. His sister had been treated for depression and a 
brother for alcoholism. He kept up with his siblings but was not 
particularly close to them. 

He had a busy practice in a large multispecialty group 
where he had a leadership role. He felt harassed by pressures to 
see patients every 1 5 minutes and to follow managed care rules. 
He yearned for the first two years of his practice when he had 
been able to spend time with his patients, but the harder he tried, 
the further behind he got. He stayed longer and longer hours to 
catch up on his paperwork. He went to the office during 
weekends when he was not on call. 

After our third session, I prescribed paroxetine. He en- 
rolled in a treatment program to learn behavioral coping meth- 
ods and cognitive reshaping. By the seventh session he felt 
better. He distanced himself from the nurse employee, intensi- 
fied his time with his wife and daughter, became self-reflective 
and insightful about his non-nurturing background, his needs 
for control and for intimacy, and his depressive outlook. He 
began to again enjoy his time with patients and to re-engage 
with the organizational tasks of practice. He renewed connec- 
tions with his siblings, further developed male relationships, 
exercised, and became involved in medical mission work. 

My diagnosis was "dysthymic disorder and marital dys- 
function in a person with obsessive-compulsive personality 



with dependent features." Treatment included evaluative con- 
sultation, goal clarification, medication, and cog- 
nitive-behavioral psychotherapy followed by psychodynamic, 
insight-oriented work. His wife was involved collaterally and 
they did some couples work together with another therapist 



Reasons for Board Action^ 

Behavioral issues underlie 44% of the interviews and 53% of 
formal Board action: substance abuse leads to 28% of inter- 
views and 26% of actions; psychiatric problems, to 6% of 
interviews and 10% of actions; sexual misconduct, to 4% of 
interviews and 10% of actions; felony convictions, to 2% of 
interviews and 7% of actions; patient complaints, to 4% of 
interviews. 

P*roblems with prescriptions precipitate 30% of interviews 
and 30% of formal actions. These include prescribing inordi- 
nate amounts of a drug, and prescribing on demand without ever 
seeing the patient, without medical reason, without documen- 
tation, without having a doctor-patient relationship, or without 
a file. Two percent of interviews and less than 1% of formal 
actions are associated with self-prescribing. 

Medical practice issues account for 24% of interviews and 
17% of actions: poororquesiionablequality of care, failure to 
provide care, unorthodox practices, and ethical lapses prompt 
8% of interviews and 13% of actions. Settled malpractice suits 
provoke 5% of interviews but no formal actions. Inadequate 
supervision of extenders leads to 5% of interviews and 2% of 
actions. Inadequate continuing education or unlicensed prac- 
tice account for 2% and 1 % of interviews, respectively, but less 
than 1 % of actions. 

Review of settled malpractice suits reveals that in 40% of 
cases they involved delayed or missed diagnoses. Surgical 
problems (postoperative complications, unnecessary surgery, 
equipment left internally, wrong-level or wrong-side surgery, 
and nonunion of fractures) account for 30% of suits. Other 
reasons include: delayed or bad outcome of delivery (7%), 
insertion of tubes or instruments into an orifice (4%), delayed 
or inappropriate treatment (3%), sexual misconduct (2%), and 
consent problems (2%). 



Who Comes Before 
the Medical Board?^'^ 

General practitioners comprise only 2% of physicians, but were 
the practitioners most likely to be interviewed and disciplined. 
A relatively high percentage of family practitioners, emergency 
medicine physicians, and psychiatrists were interviewed or 
disciplined. Surgeons, the second most-populous specialty, had 
a chance of being interviewed or acted on that was commensu- 
rate with their numbers. On the other hand, internists and 
pediatricians had a low chance of interview or discipline 
relative to the numbers of these practitioners. 



220 



NCMJ July I August 1996, Volume 57 Number 4 



Rural physicians were seen at a rale twice that of urban 
doctors, even though they represent less than half of all physi- 
cians. Males were three times more likely than females to be 
seen and four times more likely to be disciplined. There was no 
preponderance by age. 



Physicians Seen in Private Practice 

Physicians seen in one private practice of psychiatry are self- 
selected, which means that physicians with substance abuse, 
who are generally in denial, are unlikely to be seen. Denial 
certainly affects physicians summoned to the Board, but they do 
not have the opportunity to decline the summons. 

I am assessing data from my own practice. So far, the 
information shows that marital dysfunction was a primary issue 
with 50% of physicians who sought my help. Of these, almost 
half also had depression, anxiety, or both. The most common 
psychiatric diagnosis was affective disorder (46% of cases), of 
whom 60% had marital dysfunction. Half the affective disor- 
ders were dysthymic, 33% major depression, and 17% bipolar. 
Anxiety disorders were found in 7% of the physicians, half of 
whom also had marital dysfunction. 

The most common personality patterns, represented al- 
most equally, were: obsessive-compulsive, dependent (some 
with passive aggressive features), and narcissistic. This should 
not surprise us since the practice of medicine calls for attention 
to detail, structure, care taking, andself-confidence — traits likely 
to select doctors with those personality types. 

The doctors I saw most commonly were internists (30%), 
family practitioners (6%), and psychiatrists (6%). Others spe- 
cialties represented in low numbers included surgery, anesthe- 
siology, radiology, ob-gyn, urology, pathology, and pediatrics. 
Age distribution was equal forages 30 to 70. 1 saw 10 males for 
every female. 



The Benefits of Doing Something 

Physicians do well when they seek help, even when they are 
referred by the Medical Board. If they are provided with caring, 
intelligent clarification and confrontation, information, struc- 
ture, and the expectation that they can face the challenges of 
their life and its tasks, the results can be gratifying. In a few 
instances, we have seen physicians redefine not only their 
priorities but also their careers. 

The "disruptive physician" is an unfortunate and pejora- 
tive description of impairment.'* This phrase clouds our under- 
standing of what is happening. In most cases we find a person 
who is trying harder and harder to do what is right in the face of 
decreasing personal resilience and well-being. Most often there 
are patterns of obsessiveness and compulsiveness in a de- 
pressed individual with significant narcissism and dependence. 
If not engaged in a positive experience, such physicians can 
become antagonized and quite hostile. 

Other observers have written about the greater happiness 
of married people, and the protection that marriage can pro- 
vide.' Often the earliest signs of failing emotional and profes- 
sional health lead to dysfunction in the marriage.'" Female 
physicians parallel their male counterparts in this regard. Of 
particular note are the complexities they face in balancing 
motherhood and homemaking with practice, particularly in a 
profession still dominated by men. The female physicians tend 
to have obsessive-compulsive and dependent personalities, 
rather than narcissistic. With women as with men, there is a 
preponderance of affective disorders. Unlike the males, the 
female physicians are more likely to be protective of their 
marriage and their spouse. 

Medical spouses I have seen in private practice often suffer 
from depression, or function in symbiotic (co-dependent) or 
hostile-dependent patterns. They are often worried that their 
physician-spouses have alcohol or drug problems, even when 
this is not the case. Intimacy, communication, faithfulness, 
children, and depression are also key concerns. □ 



Author's note: Appended on the next page are two sections 
worth noting: personal stress modifiers, which can help all 
physicians, their spouses, and their families deal with the many 



demands of our profession: and guidelines for documenting 
and providing safe medical practice, thus avoiding an invita- 
tion to appear before the Medical Board. 



References 

1 Stratas NE, Alexander EA, Paris BD. Function of the Board of 
Medical Examiners. NC Med J 1992;53:11-2. 

2 Paiis BD, Stratas, NE. Complaint review process of the Board of 
Medical Examiners. NC Med J 1992;53:15-6. 

3 Myers M J. Treating physicians with psychotherapy. Directions in 
Psychiatry 1992;JuIy 12:13. 

4 Newton L, Stratas NE. Review of informal interviews and disci- 
plinary actions of the NC Board of Medical Examiners, 1988- 
1991. NC Med J 1993;54:625-32. 

5 Stratas NE. Exploitation and abuse of patients. SC State Medical 
Society, presentation at armual meeting, Feb. 1993. 



6 Reporton Sexual Boundary Issues from the Ad Hoc Committee on 
Physician Impairment. The Federation of State Medical Boards of 
the United States, Inc., 1996. 

7 Irons R. The behaviorally disruptive physician. Metamorphosis 
1994;winter. 

8 Coombs RH, Fawzy FI. The impaired physician syndrome. In: 
Scott C, Houck J, eds. Health Thyself. Brunner Mazel, 1986. 

9 Coombs RH. Marital status and personal well-being. Family 
Relations 1991;40:97-102. 

10 Stratas NE. Stress and the physician's family. Kentucky Medical 
Bulletin 1993;Aug. 



NCMJ July/August 1996, Volume 57 Number 4 



221 



Appendix I: How to Modify Personal Stress 



Strive for interdependence with individual responsibility. 
Clarify your goals, thoughts, values, beliefs, and questions 
and share them with your partner(s). Listen to theirs. 
Acknowledge your feelings and share them with your 
partner(s). Listen to theirs. 

Exercise responsibility for your needs, whether they de- 
pend on yourself or relationships with others. 
Acknowledge your humanness and its imperfections. Do 
the same for others. 

Exercise, eat right, get enough sleep and relaxation, and 
engage in mental activity. Be your own best friend. 
Be an optimist. Turn problems into opportunities. 



• Control how and how fast you spend your days. 

• Be flexible. Adjust to change. Do not rigidly hold on to your 
own ideas about how things have to be. 

• Commit yourself to tasks and to people. 

• Reserve time for yourself every day. Reflect and meditate. 

• Stay connected to yourself and to the people in your world. 

• Live and play, live and explore, live and learn, live and eat, 
live and sleep, live and work. But live! 

• Enjoy your peak experiences, for no reason at alL 

• Modify the intensity of your reactions. 

• Laugh and laugh at yourself every day. 

• Clarify your spiritual experience. 



Appendix II: How to Avoid An Invitation From the Medical Board 



Keep up continuing education and maintain documen- 
tation. 

Have clear contracts with patients that include your — 
and their — roles, responsibilities, and expectations. 
Document all patient contacts, and note whether pre- 
scribing in writing or by phone. 
Document complaints and elements of the interview. 
Document the complete or focused examination to 
appropriately investigate specific complaints. 
Anti-anxiety drugs work well for transitional symptoms. 
If there is a continuing need, reevaluate, consider 
antidepressants and/or a consultation. 
If pain is continuous, consider use of treatment modali- 
ties other than controlled substances, particularly in 
nonmalignant (cancerous or otherwise) situations. Re- 
evaluate; obtain a consultation. 
Watch for depression in patients. Selective serotonin 
reuptake inhibitors have minimal side effects. They are 
useful for nervousness, sleep problems, irritability, habit 
disorders, and psychosomatic and somatopsychic dis- 
orders. 



• See the patient first, then prescribe. When you continue to 
prescribe, see the patient at appropriate, regular intervals. 

• Collect and document appropriate objective data such as 
vital signs, weight and appropriate labwork, and other 
diagnostic tests. 

• When a Board investigator visits, be open. If busy, arrange 
an appointment. Investigators are agents of the Board. Be 
clear with your staff that you depend on the Board for your 
license and that respect, courtesy, and responsible prac- 
tice are required. At times, investigators may conduct 
unprovoked pharmacy reviews or office visits. 

• Be responsive when the Board requests data or an inter- 
view. If you have legal concerns, consult your attorney or 
the Board staff or members. Work to comply with the 
Board; if you have questions or want help, contact the 
Board or the Physicians Health Program. Don't wait until 
you have to. 

• It is okay to be anxious at a Board meeting. It is all right to 
talk about your feelings. Be open, respect yourself and 
your colleagues, be honest, value your thoughts, ask 
questions, say what you think. Don't be self-defeating. 



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222 



NCMJ July/August 1996, Volume 57 Number 4 




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1^ ^?P^ NORTH CAROLINA MEDICAL SOCIETY 

Health Watch 



VOL 57 - NO. 4 - JULY/AUGUST 1996 



Low Back Pain 



HELP IS AVAILABLE 

by Ranjan S. Roy, MD, PhD 



Low back pain affects almost every person at some stage 
during his or her life. It is second only to headaches as the 
leading cause of pain. Up to 80% of adults experience at least 
one episode of disabling back pain. In most cases, it resolves 
on its own within six weeks of beginning. Nearly 15% of 
people with back pain seek medical care, ranking it high as a 
reason for physician office visits. Two percent of patients 
with back pain also have leg symptoms. 

Not too long ago, treatment of patients with back pain 
was frustrating and unrewarding. This situation has im- 
proved in recent years. A better understanding of how the 
spine works and better diagnostic procedures have enabled 
physicians to successfully diagnose and treat back pain and 
return patients to active and productive lives. 



Ranjan S. Roy, MD, PhD, is a neurosurgeon with specialized 
training in back surgery associated with Microneurosurgical 
Specialists of Central Carolina in Greensboro. 



The problem 



Low back problems usually affect adults during their work- 
ing years; between the ages of 20 and 64. In fact, it is the main 
cause of disability in persons underage of 45. Surveys reflect 
a higher incidence in women and in those who work and 
reside in urban communities as opposed to rural settings. Not 
surprisingly, occupations associated with physical labor have 
a higher incidence of back-related injuries when compared to 
professions involving less active duties. 

Table 1 lists other risk factors for acute low back pain. 
Smokers are prone to coughing episodes that can place a 
strain on the spine. Nicotine in cigarettes has been found to 
reduce blood flow and oxygen to the spine, and promote its 
early deterioration. Patients in poor physical condition 
experience more and longer attacks of back pain than those 
who are physically fit. 

Up to 80% of patients have simple low back pain. In 
most cases, it is attributed to mechanical factors. These 
symptoms resolve without treatment in 90% of patients 
within four to six weeks. Even in patients with sciatica. 50% 



NCMJ JulylAugusi 1996, Volume 57, Number 4 



225 



have significant improvement within the same time period. A 
small percentage of patients will continue to have pain 
beyond six weeks. It is these individuals who may require 
special studies and laboratory testing and perhaps surgical 
intervention as their treatment. 



Table 1 



Risk factors for acute 
low back pain 

• adults age 20-64 years 

• female 

• urban home or work setting 

• sedentary occupation 

• pregnancy 

• obesity 

• cigarette smoking 

• poor abdominal and back muscle tone 



The goal of the initial assessment is to determine the 
seriousness of the back complaint. Although a specific 
diagnosis cannot be made in all cases, the physician should 
rule out serious problems. Table 2 lists some of the poten- 
tially serious conditions that can appear as low back pain. 
Tafe/e 5 classifies acute low back symptoms into four catego- 
ries. 



Table 2 



Causes of low back problems 

• Trauma (fractures) 

• Tumors of thie spine 

• Spinal infection (disc or bone infection) 

• Osteoporosis (compression fractures) 

• Abdominal/pelvic disease 

• Conditions related to arttiritis 

• Degenerative disease 



Causes of pain 

Acute lumbar strain or low back pain 

Most cases of lumbar strain come from daily events. Arbi- 
trary lifting of heavy materials, falls, and athletic injury are 
frequent causes of muscle strain and back pain. Patients with 
acute low back strain often complain of stationary low back 
pain accompanied by tenderness and spasms of the muscles 
around the spine after strenuous physical activity. This type 
of injury is seen more often in persons with poor muscle tone 
and poor posture. By contrast, athletes and healthy young 
adults seldom suffer back injury. Pain resolves within six 
weeks in 90% of patients treated with heat, anti-inflamma- 
tory agents, and a short course of bed rest. 

Trauma 

In young people, fractures of the lower spine are usually the 
result of trauma, though minor trauma can result in bone 
fractures in patients with osteoporosis and malignancy. Char- 
acteristically, this presents as back pain with or without 
sciatica. Plain x-rays can easily show this condition. Conser- 
vative treatment includes bed rest, bracing, and possibly 
surgery in the future. 

Tumors 

Spinal tumors may mimic disc rupture of the lower back, 
producing both back and leg pain. They usually cause severe 
back pain that is worse at night and not relieved by changes 
in position. Tumors begin in the spine from bone or soft tissue 
or spread to the spine from a distant source. In approximately 
20% of cases, back pain that spreads to the spine from a 
distant source is the first sign of cancer elsewhere. Specific 
laboratory testing and magnetic resonance imaging (MRI) is 
required for diagnosis. Treatment consists of surgery, radia- 
tion therapy, or both. 

Infection 

Disc space infection with spread to the vertebrae is a condi- 
tion called osteomyelitis. Patients with this problem report 
severe back pain. Risk factors include a suppressed immune 
system, intravenous drug use. previous infections and disc 
surgery. A common feature of spinal infection is that the pain 
is more severe than a physician would expect, given the 
clinical findings. Local tenderness and muscle spasm is 
common, and in some cases, fever and malaise may be 
present. Laboratory testing and MRI are helpful in diagnosis. 
Bone scanning is positive in the early phase of infection even 
though plain x-rays may be entirely normal. Diagnosis is 
confirmed by a biopsy and culture of the specimen. Treat- 
ment consists of antibiotic therapy and immobilizing the 
patient. In some cases, surgical drainage and spinal stabili- 
zation becomes necessary. 



226 



NCMJ July/August 1996. Volume 57. Number 4 



Table 3 



Classifications of low 
back symptoms 

• non-specific and focused low back pain 
not involving the leg; 

• back-related leg pain suggesting 
sciatica; 

• spinal pathology such as tunnor, 
infection, or traumatic fracture; and 

• non-spinal pathology, such as 
abdominal or pelvic problems, 
that cause low back pain. 



Sciatica 

Pain originating in the back and radiating into the buttock, 
back of the thigh, and calf muscle is defined as sciatica. The 
common feature of sciatica is nerve root compression. Al- 
though many conditions such as trauma, tumors, infection, 
and arthritis, can produce sciatica, it is usually the result of 
an extended or ruptured disc (pinched nerve). 

Patients with a herniated disc commonly complain of 
severe low back pain. The pain can begin immediately or 
within a few hours after an injury. Leg pain, numbness, or 
tingling follows along the nerve that is being compressed. 
Coughing, sneezing, abdominal straining and, at times, weight 
bearing, can aggravate symptoms. It is often relieved by 
lying down with pillows under the knees. Interestingly, an 
injury is identified in only 40% of disc herniations. However, 
physical activities involving heavy lifting or twisting mo- 
tions while moving objects are probable risk factors. The 
doctor will usually obtain a medical history and perform 
muscle strength, sensory, and reflex testing to reveal the level 
of the involved disc. Findings on an MRI or myelogram and, 
on occasion, electrodiagnostic testing (EMG), confirms the 
diagnosis. 

Treatment for disc herniation is conservative for a period 
of four to six weeks. It includes a short trial of bed rest, anti- 
inflammatory and pain medications, and perhaps physical 
therapy. In the event that pain persists, surgery is indicated. 
Surgically removing the ruptured or herniated disc is the 
procedure of choice. Recent use of the microscope during 
disc removal permits a smaller skin incision ( 1 to 1 .5 inches), 
produces less trauma to the body, and greatly reduces the risk 
of injury to nerves. In well-selected cases, the success rate 
is approximately 95% with a yearly recurrence rate of 2%. A 



newer method, percutaneous discectomy. is being performed 
by a few surgeons. Advantages of this new technique include 
a stab wound instead of an incision, earlier return to work, and 
no need for overnight hospital stays. Although the procedure 
holds some promise, the results at this time are not fully 
proven. 

Osteoporosis 

Patient with osteoporosis often have back pain. Osteoporosis 
is responsible for up to 1 .5 million fractures per year. It is 
defined as a decrease in bone density due to decreased bone 
mass or increased resorption of bone. Osteoporosis occurs 
mostly in the elderly and in post-menopausal women, al- 
though young people can have bone density loss due to other 
metabolic conditions such as an over-active parathyroid. 
Diagnosis is made by plain x-rays. Treatment consists of 
estrogen therapy. Vitamin D, and calcium supplements. The 
patient may also be given weight-bearing exercises to stimu- 
late new bone formation. 



Managing low back pain 

Conservative treatment of patients with low back pain is 
essentially the same for the first four to six weeks, no matter 
what the cause. It includes three to four days of bed rest and 
anti-inflammatory and pain medications. Longer periods of 
bed rest promote weakness of the muscles around the spine 
and a decrease in physical endurance, therefore they are not 
recommended. 

Medication 

The safest, most effective medication for sudden low back 
pain is Tylenol. Nonsteroidal anti-inflammatory drugs such 
as aspirin, Ibuprofen, Relafen, Lodine, and Naprosyn are also 
effective, but may cause stomach upset in some patients. A 
short course of steroids can be even more beneficial than 
nonsteroidals in relieving focused back pain. 

Muscle relaxants are often prescribed for low back 
symptoms under the names Flexeril and Soma. They are 
sometimes prescribed in combination with nonsteroidals, 
although no added benefit has been demonstrated over its use 
; alone. About 30% ofpatients on muscle relaxants experience 
significant drowsiness, making it difficult for patients who 
continue to work. 

Narcotic agents are more potent than anti-inflammatory 
drugs in controlling back pain. They are prescribed only on 
a short-term basis because of their potential problems. Nar- 
cotic drugs can cause drowsiness, decreased reaction time 
and judgment, and has the potential for misuse and depen- 
dency. 



NCMJ July/ August 1996, Volume 57, Number 4 



227 



Physical methods 

Physical therapy treatments can include massage, ultrasound 
heat, or cold therapy, biofeedback, electronic nerve stimula- 
tors, called TENS units, and traction for the back. Patients are 
educated about exercises and ways to avoid undue back 
irritation. Therapy is most useful for patients with muscular 
back pain. In a significant number of patients, however, 
therapy provides only temporary relief. Physical therapy 
treatments are usually not helpful for patients with sciatica. 

Injections 

Invasive procedures include injection of chemical substances 
such as steroids, pain relievers, or opium-based drugs into the 
spinal area in patients with low back pain. Unfortunately, 
there is no good evidence to support injections as effective 
therapy for low back problems. 

Evaluating the problem 

Medical History 

The patient should report back or leg pain, numbness and 
tingling, as well as any activity limitations. The duration and 
prior history of any similar episodes as well as history of 
trauma, intravenous drug abuse, or cancer should also be 
discussed. The physician should explore underlying psycho- 
logical, social, or occupational factors that may influence the 
patient's response to treatment. 

A detailed description of how the pain behaves is an 
important part of the medical history. Constant pain that 
awakens a person from sleep suggests a spinal tumor or 
infection. Low back pain radiating into the leg, particularly 
below the knee, suggests nerve root problems. Back stiffness 
that is worse in the morning and better with movement and 
anti-inflammatory drugs, implies spinal arthritis. Finally, 
back pain increased by mechanical movement and helped by 
lying still might suggest an unstable spine. 

Two symptoms that require immediate attention and 
possibly emergent surgery include rapidly progressing muscle 
weakness, such as foot drop, and an inability to control 
urination. Both conditions indicate severe nerve root prob- 
lems and a successful outcome can depend upon timing of 
surgery. 

Physical examination 

A physical exam can help the doctor separate general back 
pain from pain caused by a serious condition. It begins with 
a general observation of the patient and an inspection of the 
spine. The physician will notice if the patient grimaces in pain 
or moves around without too much discomfort. The patient's 
ability to move his or her back and hip freely should be tested. 
The doctor will manually examine parts of the low back to get 
information on muscle spasms, trigger points or pain. Fo- 
cused spine tenderness may suggest tumor, infection, or 



fracture. A specialized examination is then conducted to 
check individual muscle strength, sensation, and reflexes. A 
straight-leg raising test is performed to determine if any nerve 
root irritation exists. The test is performed with the patient in 
a reclining position. The involved leg is slowly lifted. Nerve 
pain below the knee indicates a positive result. It is made 
worse when the foot is flexed. A more specific indicator for 
a nerve root problem is back pain caused by straight-leg 
raising of the non-involved leg. 

The history and physical examination determines if the 
patient has generalized back pain, sciatica, a serious spinal 
condition, or non-spinal pathology. Once this is determined, 
the physician may order further studies and treatment de- 
pending on the patient's underlying problem. 

Diagnostic tests 

Radiographic studies include plain x-rays and computerized 
tomography (CT) scan or magnetic resonance imaging (MRI) 
of the lower back. X-rays are costly and usually not necessary 
for simple low back pain. In cases of serious spinal pathol- 
ogy, such as tumors or infection, x-rays may show destruc- 
tion of the bone and disc. X-rays are a good way to view 
compression fractures of the bone as well as other fractures. 
Inherited spine problems, such as spina bifida occulta, can 
also be visualized with plain x-rays. 

MRI is now the preferred way to study patients with 
persistent back pain or persistent sciatica. This non-invasive 
study gives doctors an excellent view of soft tissue, including 
spinal nerves and disc material. 

MRI allows doctors to classify discs as bulging, protrud- 
ing, or extruding. Bulging and protruding discs are fre- 
quently seen in patients without symptoms, but extruding 
discs usually signify sciatica. MRI is also an excellent 
diagnostic test for suspected spinal tumors and infection. 

Not all herniated or ruptured discs show up on an MRI. 
In such situations, myelography followed by CT scan is often 
performed. Myelography is an invasive technique that in- 
volves injection of a dye followed by x-rays in different 
positions. 

Sometimes electromyography (EMG) is used to detect 
injury to a specific nerve root. These tests are conducted by 
neurologists and rehabilitation specialists. They are not 
indicated for simple low back pain. 

Bone scanning is a generalized test used to evaluate low 
back pain. A radioactive material is injected into the blood, 
then spine x-rays are performed three to four hours later. 
Bone scans are very sensitive to fractures and, in fact, show 
fractures of bone much earlier than regular x-rays. They are 
not needed when a fracture shows up on a regular x-ray. □ 



228 



NCMJ July/August 1996, Volume 57, Number 4 



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A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

A North Carolina Medical Board 
Member Looks at the North Carolina 
Physicians Health Program 

Charles E. Trado, MD, FAPA 



The North Carohna Medical Board (NCMB) is mandated by the 
State to "properly regulate the practice of medicine and sur- 
gery." And the Board is to carry out this mission "for the benefit 
and protection of the people of North Carolina." The Board's 
statement of purpose captures its spirit: "The practice of medi- 
cine is a privilege. The Board, through an efficient and dedi- 
cated organization will license, monitor, educate, and rehabili- 
tate physicians and their extenders to assure their health and 
competency in the service of the people of North Carolina." I 
will look at the relationship between the NCMB and the North 
Carolina Physicians Health Program (NCPHP) as they work 
together to fulfill the mission and the vision of the NCMB. 

In 1976, the American Medical Association instructed its 
member organizations, the state medical societies, to appoint 
committees to deal with physician impairment. The purpose of 
these committees was two-fold: 1) to protect the public; and 2) 
to treat, and rehabilitate if possible, impaired physicians. Like 
most state medical societies, the North Carolina Medical Soci- 
ety (NCMS) complied with the AMA directive by creating a 
"Physicians Health and Effectiveness Committee" (PHEC) to 
help physicians whose ability to practice medicine was im- 
paired by alcohol, drugs, or mental illness. 



Origins of the PHP 

In 1981, the NC Legislature passed the Medical Practice Act, 
OS 98-14 (b), which provides that "the [NCMB] shall refer to 
the State Medical Society Physicians Health and Effectiveness 



Dr. Trado is a member of the North Carolina Medical Board, and 
a former general practitioner who now practices psychiatry at 
Medical Arts Building, 24 Second Ave. NE, Hickory 28601 . 



Committee, all physicians whose health and effectiveness have 
been significantly impaired by alcohol, drug addiction, or 
mental illness." Since then the Board has referred to PHEC all 
impaired physicians, whether or not the Board had taken overt 
disciplinary action against them. 

In the beginning, there was no exchange of information, no 
coordination of activities, and no exchange of funds from the 
Board to PHEC. In 1987, the Medical Practice Act was amended 
to allow the exchange of information and the exchange of funds 
from the Board to PHEC. Thus began a cooperative venture that 
led rapidly to the establishment of our current program for 
dealing with impaired physicians and physician assistants. (In 
this article I refer to all participants as "physicians.") 

On November 12, 1988, Harold L. Godwin, MD, presi- 
dent, on behalf of the Board, and Ernest P. Spangler, MD, 
president, on behalf of the Medical Society, signed a Memoran- 
dum of Understanding between the NCMS and the Board. The 
Physicians Health and Effectiveness Program (PHEP) thus 
formed was charged with identifying physicians impaired by 
mental illness, chemical dependency, physical illness, or aging 
problems. The goals of PHEP were to provide "timely 
intervention;. . . [to implement] appropriate measures to protect 
the public health and safety, to encourage and assist such 
physicians in effective rehabilitation efforts, and to insure the 
continued availability of the skills of highly trained medical 
professionals for the benefit of the public." 

On December 1, 1988, Robert C. Vanderberry, MD, be- 
came PHEP's first medical director. He continues in that 
capacity, assisted by a small but dedicated and hardworking 
staff. PHP has treated more than 600 impaired physicians in 
North Carolina. Over 90% have been successfully rehabili- 
tated, a remarkable achievement considering that 70% of those 
enrolled have a chemical dependency problem (see related 
article on page 196). 



230 



NCMJ July/August 1996. Volume 57 Number 4 



In order to provide financial support for the PHEP, the 
Board increased its biennial registration fee from $50 to $70 
effective January 1990. This has allowed the Board to provide 
continual financial support of PHEP, which is now called the 
Physicians Health Program (PHP). The Board will contribute 
58% to the 1996 PHP budget. Approximately 23% of the annual 
PHP budget is contributed by North Carolina hospitals; the rest 
comes from fees charged to participants (4%), contributions 
from the NCMS (3.5%), from other organizations (e.g. Medical 
Mutual, 3.5%), from physicians who have benefited from the 
program, and from miscellaneous fees (8%). 



"(A) sense of trust between the Board 

and PHP makes North Carolina's 

program one of the most successful 

and admired programs in the nation." 



What the Program Does 

There are two ways by which impaired physicians become 
involved with PHP: by self-referral or referral from the NCMB. 
When self-referred, PHP is authorized to present the physician's 
case anonymously to its Compliance Committee. Two or three 
members of the NCMB sit on this committee and report its 
actions to the NCMB. This assures that anonymous cases are 
reviewed regularly and that the physicians involved are not 
threats to the public. If there is such a threat, the Compliance 
Committee may break anonymity so that the Board can take 
whatever actions are needed to safeguard the public (summary 
suspension of license, revocation of license, informal inter- 
view, consent orders, etc.). 

The Board expects Dr. Vanderberry and his staff to act as 
advocates for all self-referred physicians, using the same sense 
of responsibility to the public that the Board exercises. To date 
the Board has had the complete cooperation of the PHP staff and 
has no doubt about their commitment to protect the public from 
dangerously impaired physicians. This sense of trust between 
the Board and PHP makes North Carolina's program one of the 
most successful and admired programs in the nation. 

Physicians who do not refer themselves are sent to the PHP 
from the Board, usually because of serious complaints from 
patients, the public, other physicians or hospitals, or because 
they have been involved in significant malpractice suits or 
disruptive behavior. Before we had a PHP, the Board was 
limited in what it would do /or these impaired physicians so it 
tended to focus on what it could do to them . Disciplinary actions 
were the rule and rehabilitation the exception. Of course phy- 
sicians were encouraged to seek treatment on their own, but 
many were "lost" in the process. 

Once the physician has been referred, the PHP staff makes 



an assessment as directed by the Board. The PHP may refer the 
patient to established assessment and treaunent centers at the 
participant's expense. The focus is on rehabilitation while 
being certain that the public is protected from the physician's 
problem. Almost all physicians with appropriate problems who 
come to the attention of the Board are referred to the PHP. Since 
90%-95% are successfully rehabilitated, many good physicians 
return to the practice ofmedicine. That's good for the public and 
good for those physicians who succumb to these problems that 
interfere with their professional and personal lives. 

The North Carolina Medical Board has a staff of well- 
trained investigators, ably directed by Donald Pittman. Before 
a physician is referred to the PHP by the Board, Mr. Pittman and 
his staff investigate the physician's difficulties. Their detailed 
report is reviewed by the Board's Investigative Committee, 
which then makes recommendations to the full Board (see 
related article, page 236). If there is evidence of substance 
abuse, psychiatric illness, sexual misconduct, disruptive behav- 
ior, or serious problems with cognition, then the physician is 
referred to the PHP for assessment and follow-up. Disciplinary 
actions, if indicated, are taken by the Board in concert with 
referral to the PHP. The physician is followed by both the PHP 
and the Board until the problem is resolved. A physician may or 
may not be allowed to practice during assessment or treatment. 
If the problem is not resolved or rehabilitation is unsuccessful, 
then the Board will take appropriate further actions against the 
physician's license. 



"A good physician who has a bad 

probiem deserves rehabiiitation; a bad 

physician who has a bad problem is 

less of a candidate for rehabilitation." 



The Goal: Rehabilitation 

In May 1980, Crawshaw sent a special communication to the 
Journal of the American Medical Association titled "An Epi- 
demic of Suicide Among Physicians on Probation."' They 
described the extreme distress experienced by the Oregon 
Board of Medical Examiners when, from June 1976, to July 
1977, eight of approximately 40 physicians on probation or 
under investigation committed suicide and two others made 
serious but nonfatal suicidal attempts.^ 

Today, Boards are more attuned to rehabilitation than they 
were in the 1970s. That's a plus as long as our present-day 
Boards remain vigilant in their duty to deter impaired physi- 
cians from harming the public. A good physician who has a bad 
problem deserves rehabilitation; a bad physician who has a bad 
problem is less of a candidate for rehabilitation. Each should 



NCMJ July/ August 1996, Volume 57 Number 4 231 



have disciplinary actions taken against them and each should be 
assessed carefully regarding potential to harm the public. 

Is the PHP worth the dollars spent on it? In my opinion, and 
that of the Board, it certainly is. That doesn't mean that the 
Board would not like the PHP to be financially independent. It 
most assuredly would, and the PHP is making every effort to do 
this. As a charter member of the PHP Board, I can vouch for its 
honest, dedicated effort to achieve financial independence. We 
would appreciate any innovative ideas of readers that would 
help us reach our goal. 

North Carolina has one of the best Medical Boards in the 
country. We believe in our mission. We have a vision of the 
future that we believe will keep us growing and developing so 
that citizens of this state will always get medical care of the 
highest quality. We know that we have one of the best, if not the 
best, rehabilitation programs in the nation helping us do our job 
to protect the public from impaired physicians and to help 



impaired physicians to once again be trusted members of their 
profession. 

Most medical boards prefer rehabilitation to punishment, 
so long as the public is protected from imminent danger from 
the actions of impaired physicians. The latter part of that 
statement is of crucial importance however, and must con- 
stantly be in the mind of every Board member in every case 
before him or her. If we can both rehabilitate and protect the 
public, arc we not living up to our mission statement and our 
vision? It would seem so. 

Lest I have lulled you into a false sense of security by 
extolling the virtues of rehabilitation, let me alert you to the fact 
that none of the Board members I have served with or serve with 
at present are reluctant to deal harshly with the bad physician. 
And may I further warn you that the PHP, also your advocate, 
demands compliance, honesty, and sincere effort from each of 
its impaired physician participants. G 



References 

1 Crawshaw R. An epidemic of suicide among physicians on proba- 
tion. JAMA 1980:243:1915-7. 



2 SchneidmanBS. Editorial. Federation Bulletin, Novembers, 1995. 



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ARMY MEDICINE. BE ALL YOU CAN BE. 



232 



NCMJ July I August 1996, Volume 57 Number 4 



A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

Physician Assistant Impairment 

A Peer Review Program for North Carolina 

Daniel E. Mattingly, PA-C, and L. Gail Curtis, PA-C 



Physician assistants (PAs) are licensed health professionals 
who practice medicine with the supervision of physicians. PAs 
provide a broad range of medical services that would otherwise 
be provided by physicians. Currently about 1,350 PAs are 
licensed to practice in North Carolina. 

Impairment of professional performance by alcohol, other 
drugs, or mental illness is common. An estimated 12% to 14% 
of physicians experience such problems at some time during 
their lives,' mostly due to chemical dependence, which affects 
about 8% to 12% of physicians.^ We have few data on the point, 
but it's reasonable to assume that prevalence of impairment 
problems among PAs is similar to that seen in physicians. 

A number of studies have concluded that the prevalence of 
alcoholism among US physicians is about the same as that of the 
general adult population of comparable socioeconomic sta- 
tus, " but that the abuse of other drugs may be slightly higher.^-*' 
Alcohol is, by far, the psychoactive substance most commonly 
used — and abused — in this country.*' This is not surprising 
since, as Sewell points out, "There is no period in recorded 
history free of references to alcoholic beverages."'" 

The North Carolina Academy of Physician Assistants 
(NCAPA) has long been aware of these issues and has made 
them a high priority, sponsoring postgraduate education about 
impairment, providing advocacy for impaired PAs, and creat- 
ing legislation to establish a program for impaired PAs in North 
Carolina. 



Mr. Mattingly is Medical Coordinator, Durham County Sub- 
stance Abuse Services, 705 S. Mangum St., Durham 27701, 
and a Board member of the NO Physicians Health Program. Ms. 
Curtis Is Assistant Professor, Bowman Gray School of Medicine, 
Medical Center Boulevard, WInston-Salem 27157, and Past 
President of the NC Academy of Physician Assistants. 



The NCAPA Health Committee 

The NCAPA established a Health Committee in 1985. Initially 
it was called the Health and Well-Being Subcommittee of the 
Professional Practice and Relations Committee. A year later it 
became a standing committee in its own right Its early focus 
was on educating Academy members and others about the 
issues surrounding impairment. An extensive library of audio- 
visual and written materials was compiled, and several educa- 
tional programs presented. The Committee offered assistance 
to any PA who requested help — usually a few each year — but 
the success of this entirely voluntary program was limited by 
two factors: 1) the initial resistance to help that is common to 
impaired individuals (see "The Riddle of the Chemically De- 
pendent Physician," page 204); and 2) the lack of legislation 
that would permit creation of a formal program for impaired 
PAs in North Carolina. A long-term goal of the Committee was 
to see enactment of such legislation. 

So in addition to its library of educational materials, the 
Committee began building bridges with people and organiza- 
tions who could assist in developing a functioning program for 
impaired PAs. The North Carolina Medical Society (NCMS) 
succeeded in obtaining enabling legislation to establish a pro- 
gram for impaired North Carolina physicians when Senate Bill 
240 was passed in 1987. In its original form, this bill was broad 
enough to apply to "all health professionals" and was nearly 
successful, but 1 1 th-hour changes narrowed the final version to 
cover only physicians. Subsequently, the NCAPA Health Com- 
mittee approached the NCMS about expanding the legislation 
to include PAs. The NCMS was supportive and together with 
the NCAPA explored how to accomplish this goal. 

The NCMS -NCAPA liaison strengthened in other ways. A 
PA was included as a consultant member of the Medical 
Society's Health Committee, and was involved in committee 
meetings as the impaired physicians program was being devel- 
oped. On the national level, NCAPA members served as repre- 
sentatives to the American Academy of Physician Assistants 
Impairment Caucus, and participated in the American Medical 



NCMJ July I August 1996, Volume 57 Number 4 



233 



Association's Impairment Conference. And — perhaps most 
importantly — the NCAPA Health Committee established a 
working relationship with Dr. Robert Vanderberry, Medical 
Director of the North Carolina Physicians Health Program 
(NCPHP). His support of our efforts has been crucial to the 
accomplishments of the Committee. 



"...as more impaired physician 

assistants are identified, 

qualified PA colleagues will be 

available to provide assistance, 

monitoring, and advocacy." 



After much hard work and collaboration, the NCAPA 
Health Committee's efforts paid off. In June 1993, the General 
Assembly ratified House Bill #56, providing peer review legis- 
lation for physician assistants. The bill was modeled after the 
physicians' legislation and became effective October 1, 1993. 
It provides the legal grounds for active intervention in cases 
involving possibly impaired PAs, and for establishing a treat- 
ment and monitoring program. It provides legal protection from 
litigation to anyone who gives information about PAs sus- 
pected of being impaired, as long as the information is provided 
in good faith. This is critical to the success of the program, 
because without such protection a person could be legally 
liable, despite all good intentions of trying to protect patients 
and to help a suffering PA. 



PA Involvement in the 

NC Physicians Health Program 

The 1993 law would allow the Academy to develop its own 
impairment program. However, Dr. Vanderberry and the 
NCPHP's Board of Directors extended the opportunity 
to join their program. NCAPA accepted this opportu- 
nity not only because it obviates the need to develop a 
program from the ground up, but also because of 
NCPHP's documented record of effectiveness, includ- 
ing a 92% success rate in treating the first 600 partici- 
pants, according to unpublished statistical data from 
NCPHP (see page 196). Furthermore, of the several 
available models of treatment and monitoring pro- 
grams," that used by NCPHP is probably the most 
effective, and is the one recommended by the American 
Medical Association.'^ In October 1994, the final steps 
in establishing a program for impaired PAs were com- 
pleted, and the Memorandum of Understanding be- 
tween the NCAPA and the North Carolina Medical 
Board (NCMB) and the contract with NCPHP, signed. 
During the eight years of its operation , the NCAPA 
Health Committee's voluntary program worked with 



20 physician assistants. In December 1994, most of these cases 
were referred to Dr. Vanderberry for assessment. He and the 
NCPHP staff worked very hard to locate and contact these PAs. 
Since then nine more cases have been referred to NCPHP: five 
by the NCMB, two by physician supervisors, one by a hospital 
employee assistance program, and one by an employer and a 
hospital chicfexecutive officer. Tables 1 and 2, below, show the 
types of problems and the results of these evaluations and 
interventions. 



Peer Review 

House Bill #56provides for peerreview of physician assistants. 
In order for true peerreview to take place, PAs must be involved 
fully in the process of dealing with our impaired colleagues. For 
this reason the NCAPA Health Committee has developed, and 
has begun implementing plans to provide Dr. Vanderberry with 
a network of trained PA monitors. To date, all eight NCAPA 
Health Committee members are available to serve as monitors 
for PA participants in NCPHP, and several can also participate 



Table 1. Problems/diagnoses of 




NCAPA Health Committee cases 






# of PAs 




Diagnosis 


(n=29) 


% 


Opioids 


7 


24 


Alcohol 


5 


17 


Polysubstance 


5 


17 


Dual diagnosis 


3 


10 


Psychiatric disorder 


3 


10 


Sexual misconduct 


2 


7 


Other 


2 


7 


Marijuana 


1 


3 


Unsubstantiated 


1 


3 



Table 2. Status of NCAPA Health Committee cases 






# of PAs 




Status 


(n=29) 


% 


NCPHP contracts 


11 


38 


NCPHP post-contract agreements 


2 


7 


sub-total 


13 


45 


Assessed and released 


9 


31 


Dealt with by NCMB before 






PAs included in NCPHP 


1 


3 


Not currently licensed in NC 


3 


10 


Not currently in NC 


3 


10 


sub-total 


16 


55 


Grand total 


29 


100 



234 



NCMJ July/August 1996. Volume 57 Number 4 



in assessments and interventions. These eight PAs are spread 
across the state from the coast to the mountains, and plans are 
being made to expand this network to ensure that, as more 
impaired physician assistants are identified, qualified PA col- 
leagues will be available to provide assistance, monitoring, and 
advocacy. The support of competent and compassionate volun- 
teer monitors, and Dr. Vanderberry's excellent program, help 
protect the safety and well-being of patients, and allow suffer- 
ing PAs the opportunity to resume happy, fulfilling, productive 



professional lives. 

North Carolina can take pride in the fact that both physi- 
cians and physician assistants in this state lead the nation in 
efforts to combat professional impairment and ensure quality 
health care for its citizens. We are indebted to the North 
Carolina Medical Society, the North Carolina Medical Board, 
and Dr. Robert Vanderberry for their support of our efforts to 
achieve what we have these past few years. We look forward to 
working together in the future. Q 



References 

1 Talbott GO, Benson EB. Impaired physicians: the dilemma of 
identification. Postgrad Med 1980;68:56-64. 

2 Blondell RD. Impaired physicians. Substance Abuse 1993; 
20:209-19. 

3 Vaillant GE, Bright JR, McArthur C. Physicians' use of 
mood-altering drugs: a 20-year follow-up report. N Engl J Med 
1970;282:365-70. 

4 Bissel L, Jones R. The alcoholic physician: a survey. Am J 
Psychiatry 1976;133:1142-6. 

5 McCue J. The effects of stress on physicians and their medical 
practice. N Engl J Med 1982;306:458-63. 

6 McAuliffeWE, RohmanM, SantangeloS, FeldmanB.Magnuson 
E, Sobol A, Weissman J. Psychoactive drug use among practicing 
physicians and medical students. N Engl J Med 1986;315:805-9. 



7 Vaillant GE, Sobowale NC, McArthur C. Some physiologic 
vuhierabilities of physicians. N Engl J Med 1972;287:3732-5. 

8 Bartholomew S.Thecrisisofpsychoactivesubstanceabuse. J Am 
Acad Phys Assist 1992;5:4734. 

9 National Institute on Drug Abuse. NIDA Capsules. Rockville, 
MD: The Institute, 1985-87:Cap 02-25. 

10 Sewell R. Alcoholism: strategies for intervention. Phys Assist 

1989;13:50-8. 

1 1 Wolf K. Identifying the impaired professional: case-finding mod- 
els to identify and refer the impaired professional. EAP Digest 
1982;2:32-9. 

12 American Medical Association Department of State Legislation, 
Division of Legislative Activities. Model Impaired Physician 
Treatment Act. Chicago: American Medical Association, 1985. 



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NCMJ Julyl August 1996, Volume 57 Number 4 



235 



A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

Physician Prescribing 
of Controlled Drugs 

Perspectives of the North Carolina Medical Board 
and the State Bureau of Investigation 

Donald Pittman and R. Keith Bulla 



I. Perspective of the NCMB 

A single prescription may represent overprescribing! 

Is this possible? Seen through the eyes of a Medical Board 
investigator, this slatemcnl might be summarized by 
noting the Board's position statements, adopted May 
1991: 

1. No prescription for controlled substances or mind- 
altering chemicals should be issued by a practitioner 
for personal use. (Table 1, at right, lists conU'olled 
substances and their classification.) 

2. It is the position of the North Carolina Medical Board 
that a physician should not, in general, prescribe for 
family members. 

The Board makes several other key points: written records 
should be maintained if a physician does write a prescrip- 
tion for a family member; prescriptions should be written 
for conditions that lie within the scope of the physician's 
medical practice; family treauncnt should be reserved for 
minor illnesses, temporary, or emergency situations; and 
appropriate consultation should always be obtained for 
the managcmentof major or prolonged illness. By follow- 
ing these recommendations, physicians licensed to prac- 
tice in North Carolina will be unlikely ever to attract the 
attention of the Board's investigators. 



The Vigilance of 
the Medical Board 

Because of the problems that do occasionally arise, the 
Board's investigators are alert to physicians' prescribing 



Table 1. Federal schedules of controlled substances 

Schedule I. No approved medical use (street drugs). 

Schedule II. High potential for abuse. Prescriptions must be 
written, not verbal. No refills. 



dextroamphetamine sulfate 
fentanyl citrate 
hydromorphone HCL 
meperidine HCL 



methamphetamine HCL 
morphine sulfate 
oxycodone HCL 
secobarbital sodium 



Schedule IIL Some potential for abuse. Prescriptions may be 
oral or written. Up to five renewals are permitted within six 
months. 



acetaminophen with codeine 

butalbital/caffeine/aspirin 

hydrocodone/guaifenisin 



paragoric 
testosterone 
pentobarbital sodium 



Schedule IV. Low potential for abuse. Prescriptions may be oral 
or written. Up to five renewals are permitted within six months. 



aprazolam 
chloral hydrate 
diazepam 
donazepam 



meprobamate 
phenobarbital 
pemoline 
propoxyphene HCL 



Schedule V. Low abuse potential. Subject to state and local 
regulations. A prescription may not be required. 



acetaminophen w/codeine 
kaolin/pectin/paregoric 



guaifenesin w/codeine 



236 



NCMJ July! August 1996, Volume 57 Number 4 



patterns, especially the issuing of prescriptions to patients 
whose last name is the same as the physician's. Their ears are 
attuned to pharmacists' comments and questions such as, "Are 
physicians allowed to prescribe controlled substances to family 
members?" These items energize the investigator's keen sense 
of curiosity: "Is Jane Doe related to Dr. Doe?" "Does Jane Doe 
bring the prescription to be filled or does Dr. Doe?" "How often 
and for how long has Mrs. Doe been getting prescriptions from 
her husband?" "Do you know whether Jane Doe takes prescrip- 
tions to other pharmacies?" After the investigator gets the 
details, he may visit the physician to inquire about the prescrip- 
tions written for other family members — spouse, children, 
brother, sister, etc. 



"In most cases in which physicians 
prescribe for a family member, the 

issue is resoived when the Board 
sends the physician a ietter 

outlining its position statement." 



In most cases in which physicians prescribe for a family 
member, the issue is resolved when the Board sends the physi- 
cian a letter outlining its position statement. However, some 
reports require extensive review by the Board because of the 
level of concern. In fact, one such case could be resolved only 
by removing the physician's privilege to practice medicine for 
a period of time. Initially, this physician was writing analgesic 
prescriptions for his wife. The Board strongly encouraged him 
to delegate the responsibility for his wife's medical care to 
another physician. Later, there were more prescriptions plus 
purchases from a second pharmacy for the same medication, 
ostensibly for "office use." The physician was interviewed by 
the Board members about his continued medical treatment of 
his wife. A consent order was executed which included a public 
reprimand for his prescribing practices. 

All was quiet then for a while until an investigator was 
informed that the physician had obtained the same medication 
from a hospital pharmacy. During another interview before the 
Board, the physician admitted that he had resumed treating his 
wife. This news and discussion with the Board resulted in the 
surrender of his medical license. Six months later, the Board 
granted him a temporary license along with the caveat: "Del- 
egate all medical treaunent of his wife to another physician; do 
not prescribe any medications to her." 

Several months later, the physician relocated to another 
area of the state and resumed practicing medicine. After a few 
weeks of employment, drugs were discovered missing from the 
medical clinic office supply. After a thorough investigation, the 
Board allowed the physician's temporary license to expire and 
not be renewed. He was unable to practice for three years. He 
is now practicing again, but remains under the "watchful eyes" 
of the Board and its investigative staff. 



How Doctors Divert Drugs 

As challenging as the preceding case was for the Board's 
investigators, there are even more deceptive ways of getting 
drugs. Physicians who prescribe for themselves do not simply 
write a prescription in their own name, sign and take it to a local 
pharmacy for filling, especially if their perceived need for the 
medication has become "long-term." The physician will write 
a prescription in the name of an employee or friend, and request 
that person, after getting the prescription filled, give him part or 
all of the medicine. Or the physician may remove drugs from his 
own office stock, manipulating the inventory records to cover 
up his "theft." 

Injectable drugs are "stolen" by medical personnel, includ- 
ing physicians. The drug is removed from the vial and saline 
substituted or, after the drug is appropriately administered to a 
patient, any remaining material is not properly disposed of (two 
or more people should witness the disposing of the wasted drug) 
but diverted to personal use. Hospital-based physicians are 
constantly faced with the temptation of easy access to injectable 
narcotics. As a medical provider, be attentive to signs of diver- 
sion: repeated reports from patients who experience pain during 
a procedure despite having had an appropriate analgesic dose of 
medication administered; or proper procedures for disposal of 
waste drugs are not followed; or a particular medical provider 
regularly offers to work other providers' night and weekend 
shifts in the operating, recovery, or emergency room. Regard- 
less of whether the suspected individual is a physician, nurse, 
anesthetist, technician, or other care provider, you should report 
any suspicion of drug diversion to the appropriate regulatory 
agency and/or the State Bureau of Investigation. 



". . .you should report any suspicion 

of drug diversion to the appropriate 

regulatory agency and/or the 

State Bureau of Investigation." 



A episode of diversion occurred recently in a small hospi- 
tal. A drug mixture, which included a narcotic, was prepared for 
use in the hospital operating room by either a physician or a 
hospital pharmacist. Questions were raised about the integrity 
of the mixtures when they were prepared by the physician. 
Several samples were tested in an independent laboratory 
which reported that the narcotic drug had been diluted. Al- 
though initially denying diversion, the physician eventually 
admitted to secreting the drugs for his personal use. His medical 
license was suspended; he sought drug treatment, signed a 
Physicians Health Program (PHP) contract, and eventually was 
able to return to medical practice. 

Another example involved a physician and his employees. 
In order to conceal his personal use of a con&oUed substance, 
the doctor wrote prescriptions to various employees who filled 



NCMJ July/August 1996, Volume 57 Number 4 237 



these prescriptions at different pharmacies. The employee then 
brought the medication back to the office and gave the prescrip- 
tion bottle to the physician. When confronted, the physician 
admitted that he was self-prescribing. After careful review and 
consideration by the Board, the physician signed a PHP contract 
and was directed to abide by its terms and conditions. The Board 
monitored his compliance for an extended period. 



Physician Extenders 

Physician assistants and nurse practitioners are not exempt 
from the Board's position statements or the watchful eyes of the 
investigators. Before 1994, physician extenders in North Caro- 
lina depended totally on the supervising physician to prescribe 
controlled substances. Sometimes, for convenience, physicians 
would pre-sign prescription blanks for use by the extender 
when seeing patients who were taking a controlled substance 
medication. This method of prescribing was not and is not 
tolerated by the Medical Board because pre-signcd prescrip- 
tions provide a convenient opportunity to divert medicine to the 
extender, family members, or friends. Over the years the 
Medical Board has disciplined several extenders and their 
supervising physicians for just such activities. Now extenders 
can obtain a mid-level practitioners' Drug Enforcement Ad- 
ministration number, which authorizes them to prescribe con- 
trolled substances, but the Board's investigators are still alert to 
the use of pre-signed prescriptions and will make every effort 
todetermineunderwhatcircumstancesand for whom they were 
written. 



Avoiding the Pitfalls of Prescribing 

It is likely that sometime in the careers of all physicians they are 
asked by a physician-colleague for a prescription medicine. 
Wrong? Not necessarily, but such "curbside" consultations 
always generate curiosity and questions from the Board's 
investigators: 



"Did the recipient of the prescription ask for a specific drug 
without giving any valid medical reason for it? 

"Was this a one-time only request? Or does the colleague 
request the drug on a continuing basis... virtually every time 
their paths cross in a hospital hallway or physician's lounge? 

"Has the physician requested similar drugs from multiple 
colleagues all in a brief time span? 

"Did the prescribing physician ask his colleague what 
other medicines he is taking, for what reasons, and by whom 
were they prescribed?" 

Impaired physicians, even those who have completed 
inpatient and aftercare treatment and are successfully working 
on their recovery program, are at least bordering on relapse 
when they ask another physician or dentist to prescribe con- 
trolled substances without even giving the colleague a chance 
to "Just say no." Unsuspecting colleagues may prescribe a 
supply of the drug not only for some seemingly reasonable 
period of time, but may be asked to authorize refills "in case" 
the friend's symptoms persist. Impaired or relapsed physicians 
may call their physician or dentist the day after filling an initial 
prescription, claiming that the drug is "too strong" or "too 
weak," and ask that a prescription be phoned in for a different 
drug. The prescriber may do so, again possibly with refills. 
Unbeknownst to the prescribing doctor, the "patient" fills both 
prescriptions plus refills. Imagine this scenario multiplied across 
two, three, or more physicians and dentists who are unwittingly 
prescribing medications to their colleague. Ask yourself, is it 
possible that just one prescription is overprescribing? How 
about when a "good-hearted" physician, even unintentionally, 
writes one prescription for an impaired colleague? Ask your- 
self, if you have been or, more importantly, are being tempted 
to "overprescribe" — for friends, family, colleagues? If not, 
consider yourself blessed. But, if you are, consider the conse- 
quences. A one-time prescription for a family member may 
result only in a letter from the Medical Board informing you of 
its position statement. But multiple prescriptions to loved ones, 
self-prescribing, secretive visits to the narcotics cabinet, na- 
ively prescribing to a colleague, all bring severe consequences. 

—Donald Pittman, Director, 

Department of Investigation, 

North Carolina Medical Board, Raleigh 



II. Perspective of the SBI 



It is important for health professionals to remember that being 
impaired is not illegal. However, without intervention and 
treatment, impaired professionals often resort to illegal diver- 
sion of drugs for personal use. All investigations of drug-related 
misconduct by health care professionals are carried out by the 
State Bureau of Investigation's (SBI's) Diversion and Environ- 
mental Crimes Unit. 

In almost every diversion investigation we find an element 



of overprescribing at some stage as the problem is developing. 
The overprescribing may or may not actually lead to impair- 
ment, but it is usually involved in supporting an impaired 
physician. In any case, we must begin by addressing the 
difference between the practice of medicine and the disu^ibution 
of controlled substances. Since 1974, the SBI has been respon- 
sible for investigating the diversion of pharmaceutical drugs, 
including diversion by physicians. 



238 



NCMJ July/ August 1996, Volume 57 Number 4 



Prescriptions in the 
Practice of Medicine 

Overprescribing? Underprescribing? Is this patient seeking 
help or just seeking dnigs? Every day physicians are bom- 
barded with needs, requests, problems, information, the stric- 
tures of guidelines and regulations. As a result, there are many 
different theories and opinions about when to prescribe, when 
not to prescribe, and what to prescribe. I cannot cover all these 
matters, but I do want to raise a couple of general points: 

1. Many self-prescribing physicians say, "I've only been 
taking this medication for a short time. I can manage my own 
care, after all, I'm a physician; I'm trained to prescribe drugs." 
Have you ever had these thoughts? I warn the reader about this 
dangerous line of thinking. 

2. I have a growing concern about the vulnerability of 
younger physicians who grew up surrounded by a high level of 
"recreational drug use." In the past, most of the cases we 
investigated involved practitioners who began using drugs to 
cope with stress and burnout. Now, that is changing. Drugs are 
being used for pleasure. Doctors and other health professionals 
are as vulnerable as anyone else. 

In my experience, I have noted that physicians have only a 
general understanding of what is legally required in writing a 
prescription. Some think that any prescription written by any 
licensed physician is legal and valid. Others cite the need for 
elaborate office procedures and records to satisfy the require- 
ments. If we stopped here, how would you explain your deci- 
sion to write the last controlled substance prescription you gave 
to a patient? Do you consistently apply these guidelines to all 
patients? It is certainly true that physicians must be free to treat 
patients without interference, within the constraints of good 
practice. At the same time, physicians cannot distribute or use 
drugs willy-nilly, behind a shield that every prescription is 
automatically legal and valid. Therefore, both state and federal 
regulations address the requirements of a prescription. 



Prescribing Properly 

To be valid and appropriate, prescriptions must meet a 
two-pronged test: 

1. Prescribing, dispensing, or administering controlled sub- 
stances must be undertaken for legitimate medical purposes; 
and 

2. Prescribing, dispensing, or administering controlled sub- 
stances must be in the usual course of the individual 
practitioner's professional practice. 

All prescribing, dispensing, and administering of con- 
trolled substances is subject to review and must meet these two 
simple requirements. If you practice medicine, even bad medi- 
cine, within these guidelines, you should be safe from review by 
law enforcement. However, if you write prescriptions or obtain 
drugs for personal use under the guise or pretext of practicing 



medicine, you will be subject to state or federal court sanctions. 
Over the years, the courts have set out criteria and ex- 
plained the process of meeting the requirements for a valid 
prescription. These criteria emphasize that professional prac- 
tice must include a bona fide physician-patient relationship. 
Such a physician-patient relationship arises when: 

1. The patient comes to the physician for the purpose of 
obtaining u-eatment of an illness or a condition; 

2. The physician conducts a verbal or physical or laboratory 
examination of the patient's health, condition, and medical 
history; and 

3. There is a reasonable nexus between the drug prescribed, 
dispensed, or administered and the patient's legitimate medi- 
cal needs. 

Unlike some states. North Carolina does not limit the 
quantity of drug prescribed or limit dispensing to conditions 
that meet Food and Drug Administration-approved indications. 



The Role of the SBI 

SBI investigations of the prescribing, dispensing, or adminis- 
tration of controlled substances involves determining whether 
the acts met the guidelines as defined. If the guidelines were not 
met, the activity does not have the "protection" of medical 
practice, and becomes subject to criminal review by the courts. 
Investigations that involve only overprescribing are usually 
referred to the NCMB; the role of the SBI is to investigate 
criminal acts: the illegal possession of drugs and the manner in 
which they were obtained or distributed. Both the person 
obtaining the drugs and the person who delivered or authorized 
the delivery are investigated. By definition, prescribing, dis- 
pensing, and administering are all considered a delivery. 

The illegal activity that accounts for most criminal inves- 
tigations by the SBI in North Carolina is diversion or embezzle- 
ment NC General Statute 90-108 (a) (14) addresses diversion 
of drugs by persons (including physicians) who have legal 
access by virtue of their employment. Any person who has legal 
access and who embezzles, diverts, or misapplies the drug 
violates the criminal statutes. 

When a physician starts to abuse a controlled substance, a 
supply of the substance is needed. Without intervention and 
treatment the problems continue and the need for more drugs 
and new sources escalates. Physicians and other health care 
professionals sometimes place their own drug needs above the 
needs of patients. How the physician obtains drugs is the usual 
point at which criminal law applies. The simplest source of 
drugs is one that does not involve others. In the usual case this 
means self-prescribing, either by writing a prescription or by 
taking from the sample stock. Considering the guidelines for 
valid prescribing, it is easy to see how difficult it is to establish 
a physician-patient relationship with oneself. The North Caro- 
lina Medical Board has issued a position on self-prescribing 
(stated in Part I). 



NCMJ July/August 1996, Volume 57 Number 4 



239 



Impaired physicians who need more drugs than they can 
self-prescribe may turn to fellow physicians for "help." This 
means another physician becomes involved and subject to the 
prescribing requirements. The prescribing physician must es- 
tablish that physician-patient relationship. I often hear that the 
prescription in question was written as a "professional cour- 
tesy" to a fellow physician. This does not avoid the conse- 
quences of wrongdoing. 

A physician who seeks prescriptions from a colleague must 
be straightforward in presenting information. Feigning symp- 
toms or withholding information about getting the same or 
similar drug in a concurrent lime period from others may violate 
the "Doctor shopping" statute (NC GS 90-108) (a)(13). 

We have had cases of physicians who wrote prescriptions, 
but requested that the patients return part of the drugs to the 
office for "office stock" or that they surrender leftover drugs for 
the "patient's safety." Another variation is to give the patient an 
extra prescription to be returned later to the office. All of these 
actions represent obtaining drugs by fraud, deceit, and subter- 
fuge. All are illegal. 

The most serious type of diversion is dilution, substitution, 
or denying a patient medication. The operating room, emer- 



gency room, and office examination room afford the opportu- 
nity for physicians to dilute or substitute medications to a 
patient. Investigation of this type of diversion usually results in 
criminal charges, regardless of any action taken by the Medical 
Board. 

Physicians develop drug and alcohol problems at a rale at 
least equal to the general population, despite their training, 
education, and experience in recognizing problems in others. 
Few physicians tell patients to "heal themselves;" but physi- 
cians routinely deny their own need for help. Denial is the 
strongest single factor perpetuating addiction and the one most 
in need of outside help to overcome. North Carolina has a model 
program for helping physicians with chemical dependency. 
Use it at the very earliest signs of a developing problem. Your 
chance of recovery is greater and the impact on your practice, 
license, and life is reduced. Physicians who play the denial 
game risk a devastating blow to their patients and their careers. 

To North Carolina physicians I say, practice good medi- 
cine. Set an example by your practice. And recognize when to 
be the physician and when to be the patient. 

— R. Keith Bulla, Special Agent-in-Charge, 
State Bureau of Investigation, Greensboro 




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Front Line Recovery 

Motoring Across North Carolina 



Carsten Thuesen, CSAC 



I am Western Field Coordinator for the NC Physicians 
Health Program (NCPHP). I've often wondered if Governor 
Hunt or the NC Department of Transportation could use my 
consultative expertise about roads, landscaping, or traffic 
patterns from Raleigh to Murphy. I developed it during four 
years of monitoring physicians and physician assistants for 
the NCPHP. I have covered more than 150,000 miles and 
have had experiences "TNTC," as health care providers like 
to say. 

I will explain my monitoring role, but let me first make 
a pitch to Dr. Vandcrberry for hazardous duty pay! Most 
weather fronts in North Carolina move from west to east. As 
I plan my travels. The Weather Channel becomes my ally . It 
is not unusual to start with a gorgeous blue sky only to be 
pounded by a driving rain before the day is out. One day I 
walked into a doctor's office in the mountains at 10 a.m. and 
came out at 11:30 a.m. facing acombination of rain, freezing 
rain, ice pellets, and snow. All of these heavenly precipitanls 
were blowing straight sideways! I beat a hasty retreat back 
to my home near Charlotte. 

Perhaps Southern Bell, GTE, BTl, etc., would like me 
to report on the state of their pay phones. It is a real feat to 
be beeped, get off at the next exit, and find a working phone. 
Some lack receivers, others look serviceable but have no dial 
tone, and some units have been beaten to death by enterpris- 
ing thieves for a $1.35 haul. The crowning blow came one 
night behind a fast food restaurant where I finally found a 
working phone. I became separated from my car by four men 
seeking more than my autograph. Fortunately, God pro- 
tected me. One of the four was a former patient of mine 
during the time I served as counselor in a Charlotte chemical 
dependency unit! The situation quickly reversed from one of 
danger to an opportunity to get the now crying mugger back 
into treatment. Following that event the NCPHP fast-for- 
warded its request for my cellular phone. 

The above-mentioned situations were irritants, not ob- 
stacles. They are only a tiny part of a job that I love: 
monitoring the aftercare plan of physicians and PAs after 
they finish appropriate treatment. Often I meet these partici- 
pants in the treatment center before discharge and go over a 
"u-eatmcnt plan contract" drawn up by Dr. Vanderberry . My 
job is to set up the recovery network for each individual and 
to make suggestions for other family members. Since 



65%-70% of NCPHP participants have chemical depen- 
dency problems, I often focus on 12-step recovery pro- 
grams: meeting frequency, locations of meetings, the need 
for a 1 2-slep sponsor, and meetings and counselors who can 
help the spouse and children. I also arrange for a NCPHP- 
sponsored physician-monitor in the community. That moni- 
tor is in position to know how the practitioner is doing in the 
hospital, how he or she is received in the community, and 
whether his or her behavior is erratic. The monitor and I visit 
the participant twice a month, and one or both of us obtain 
random urine drug testing as proof of sobriety. As I continue 
to meet with the physician or PA over time, I develop "a feel" 
for the participant's recovery. This is very important when 
or if the participant appears before the NC Medical Board 
and I must attest to the quality and sincerity of the person's 
recovery. 

As a field coordinator I am trained to combat chemical 
dependency and as such am on the front line in trying to 
identify the needs and progress of impaired physicians and 
PAs. These individuals are not bad people; they have a 
disease. Some do have difficulty being accepted back into 
their communities because many people feel that addiction 
is a "weakness" or moral issue, not an illness. Participants 
often fear being "found out" because they worry that fellow 
physicians and patients will not understand. In most cases, 
those fellow physicians and patients suspected the problem 
any way. In fact,paticnlsaremore"forgiving" of an impaired 
physician's transgressions than are his or her colleagues. 
Recovering physicians need to be understood by their peers. 
They need community support. What they come to realize is 
that trust is often slow in coming, but once in recovery most 
physicians rebound from impairment to become respected 
practitioners in the community. 

My job is rewarding and the contributions of these 
recovering physicians is ever more apparent as we approach 
the year2000. Ninety percentofall my physicians work hard 
at their recovery. Many now work in areas that are not 
particularly glamorous, dealing with the elderly, indigent, 
and predominately Medicare and Medicaid patients. These 
health care providers are so grateful to be out of the chemical 
bondage and overwhelm ing obsession of their dependencies 
that ihcy view their practices as ministry. They reach out to 
others who need help. I am impressed with my clientele. □ 



242 



NCMJ July/ August J 996, Volume 57 Number 4 



A HEALING HAND FOR PHYSICIAN IMPAIRMENT 

Into the Next Century 

A Strategic Plan for the North Carolina 
Physicians Health Program 

Julian F. Keith, Jr., MD 



In March 1995, the staff and Board of Directors of the North 
Carolina Physicians Health Program (NCPHP) developed a 
strategic plan to guide program development for the remainder 
of this century and into the 21st century. 1 provide here a 
summary of the process and results of that activity. 

The first step consisted of an in-depth review of the history 
of the Program since its inception in 1988, the growth in number 
of participants served, and the rehabilitation and education 
services offered. Governance and management structure were 
assessed, including the Memorandum of Understanding be- 
tween the Program and the North Carolina Medical Board 
(NCMB) and the relationship of the Program to the North 
Carolina Medical Society. 

The strengths and weaknesses of the Program and its 
services were analyzed in view of the critical issues and trends 
in the external environment likely to increase the stress on 
health care professionals, and increase their risk of impairment. 
It is important to note that the staff and directors of the Program 
estimate that 13%-15% of practicing health professionals are 
currently impaired. 

The nature and severity of the impairments suffered by 
health professionals are similar to those of the general popula- 
tion. These include alcohol and other drug abuse disorders, 
mood and anxiety disorders, somatoform disorders, sexual and 
gender identity disorders, adj ustment disorders, and conditions 
associated with aging and cognitive impairment. Many of these 
impairments have their genesis in the stresses and stains 
associated with the health care field. In addition, up to 40% of 



Dr. Keith is a physician with Substance Abuse Ser'Jices, North 
Carolina Department of Human Resources, 325 N. Salisbury 
St., Raleigh 27603. He is a member of the NCPHP Board and the 
Medical Society's Physicians Health Committee. 



health care professionals come from dysfunctional families and 
cultures, and this increases their risk of being impaired by one 
or more of the aforementioned disorders. Taken together, this 
information means that the thrust of the Program in the future 
must include not only outreach, intervention, and treatment of 
impaired health professionals, but also efforts to reduce the risk 
of impairment by primary prevention. 

NCPHP's mission, briefly stated, is to improve the quality 
of health care for the people of North Carolina by assuring 
healthy medical professionals. The constituents served are 
those over whom the North Carolina Medical Board has juris- 
diction; in addition, medical students, through Memoranda of 
Understandings with the Schools of Medicine, are included. 

Program goals are as follows: 

1. Protection of the health, welfare, and safety of patients 
through the identification of impaired physicians, physician 
assistants, and medical students; 

2. Rehabilitation of impaired physicians, physician assistants, 
and medical students. Family members and significant oth- 
ers are to be included in the treaunent/rehabilitation process; 

3. Education of health professionals about impairment and its 
associated potential liability; 

4. Reduction of the risk of impairment by introducing primary 
prevention procedures into schoolsofmedicine,postdoctoral 
training programs, and professional societies; 

5. Development of affiliation with volunteer individuals and 
organizations having similar missions and goals; 

6 Attraction of volunteer leaders and employees of the highest 
quality to ensure the quality and integrity of the Program 
through accepted management practices; and 

7. Securing of sufficient funds for the ongoing operation of the 
programs. 

The guiding principles of the Program are basically 
similar to those used in other states: 

1. The Physicians Health Program must be motivated and 



NCMJ J ulyl August 1996, Volume 57 Number 4 243 



guided by humanitarian concern for public 
safety and welfare as well as concern for im- 
paired health care professionals, medical stu- 
dents, and families; 

2. Alcoholism, other drug dependencies, and 
mental illnesses should be viewed and man- 
aged as treatable conditions. 

3. The Program's treatment/rehabilitation mod- 
els should employ state-of-the-art practices that 
provide good recovery rates for all impair- 
ments treated. 

Of course. Program planning for the years 
beyond 1996 and into the 2 1st century, although 
based on past experience, must of necessity, in- 
clude several assumptions, including: 

1. The percentage of professionals who are im- 
paired will increase, both because of stresses 
induced by rapid changes in the health care 
delivery system, and because of improved 
definition and identification of impairments 
other than alcohol and drug abuse. 

2. The number of clients reported and referred to 
the Program will increase because of en- 
hanced efforts in primary prevention, out- 
reach, and intervention. 

3. Mandatory reporting of impaired profession- 
als will increase the need for additional as- 
sessment, treatment/rehabilitation, and after- 
care monitoring services. 

4. The percentage of impaired professionals who 
actually enroll in the Program will increase as 
a result of educational programs and the en- 
hanced scrutiny of physicians by hospital 
practices, HMOs, PPOs, MCOs, and similar 
groups. 

5. Through a Memorandum of Understanding, 
the Program will be operationally and admin- 
istratively independent of the NCMB. The 
program staff and the Compliance Commit- 
tee will report regularly to the NCMB on 
issues affecting the Program. 

6. Rehabilitation will continue to be nondisciplinary in char- 
acter and confidential in practice. 

7. Impaired professionals who fail to participate or otherwise 
cooperate will be referred to the NCMB for disciplinary or 
other action to bring about rehabilitation. 

8. Because family members are invariably caught up in the 
professional's dysfunctional state, family counseling will 
be an integral part of the rehabilitative process. 

9. In 1995, a relapse prevention component, using estab- 
lished and proven models, was added to the monitoring 
program. 

10. There will be an ongoing effort in hospitals and other 
medical centers to expand the number of Physician Com- 



Table 1. Number of potential participants in 
NC Physicians Health Program 



Year 


1994 


1995 


2000 


Physicians' 


14,242 


14,300 


15,000 


Physician assistants' 


1,148 


1,150 


1,200 


Families^ 


many 


many 


many 


Medical students^ 


1,600 


1,600 


1,600 


Other health care professionals 











Total # practicing 


16,900 


17,050 


17,800 


# estimated impaired" 


2,468 


2,478 


2,600 


NCPHP serve 


215 


271 


400 


% of total impaired 


9% 


11% 


15% 



'Number of physicians/physician assistants licensed and practicing in North 
Carolina according to NCMB. 

'assume, family member = [number of new cases x2]+[50% number of cases 
being monitored x2] 

'assume: medical students = average number of medical students x number of 
medical scfiools in Nortfi Carolina 

'assume, use current national average for pfiysician/physician assistant impair- 
ment composed of 13% cfiemical- and 2% psycfiiatric-related and realize ttiat 
percentage may increase in future. Estimate 10% of all medical students are 
impaired. 



Table 2. Sources of referrals to NC Physicians Health Program* 



Year 

NC Medical Board 

Physician colleague/Local PHP 

Self-referral 

Hospital administration/chief of staff 

Impaired physicians program in other state 

Treatment centers 



*Less than 2% referred from the aggregate of the following sources: spouse, 
anonymous, attorney, drug enforcement administration, dean of students, 
patient complaint. 



1994 


2000 


48% 


30% 


16% 


28% 


14% 


14% 


10% 


20% 


6% 


4% 


4% 


2% 



mittees working toward the goals of primary prevention, 
identification, and outreach/intervention. 

11. The staff of the Physicians Health Program will develop 
and maintain the cognitive and operational skills needed to 
deal with all aspects of professional impairment. 

12. The professional staff, including physicians and trained 
counselors, will be enlarged to meet the needs of those 
served. 

Tables 1 and 2, above, note the number of potential parti- 
cipants and the sources of referral for the years 1994, 1995, and 
2000. As the number of clients served increases, program 
expenses are expected to grow from $461,000 in 1994 and 
5608,000 in 1995 to $931,000 in the year 2000. Major sources 



244 NCMJ July! August 1996, Volume 57 Number 4 



of revenue include participants, the NCMB, the North Carolina 
Medical Society, member hospitals of the North Carolina 
Hospital Association, insurance companies, pharmaceutical 
companies, and individual contributions. 



Summary 

The staff and Board of Directors of NCPHP have developed a 
strategic plan to carry the Program into the next century. The 
goals of the plan are: 1 ) to reduce the risk of impairment among 



medical health care professionals through the application of 
primary prevention principles, 2) to provide improved out- 
reach/intervention su^ategies for impaired professionals, and 3) 
to provide state-of-the-art treatment/rehabilitation services for 
impaired professionals and their families. Of course, appropri- 
ate staffing and fiscal resources will be a critical pan of this 
process. □ 

Acknowledgment: S. Kathryn Page, Senior Consultant, Winslow 
and Associates, Inc., Winston-Salem, provided invaluable tech- 
nical assistance during the strategic planning process. 



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NCMJ July/August 1996, Volume 57 Number 4 



245 



FIRST-PERSON PHYSICIAN 



Anger/Avarice/Angst 

A Report From the Malpractice Battlefield 



James A. Bryan, II, MD 



Recently I finished a personal experience all loo common to 
folks in medical practice — a trial for alleged medical malprac- 
tice. It ranks as "one of my worst experiences," an opinion 
shared by the many colleagues who have told me of similar 
episodes in their lives. It has changed my attitude and the way 
I deal with patients, patient care, interactions with patients' 
families, and most certainly my feelings about the legal system 
and "hired gun" expert physician witnesses. 

In the 1970s a student from the University of Notre Dame 
was referred to me with stage I sarcoidosis causing nodal 
enlargement. He had known Gilbert's syndrome and a three- 
year history ofnonspecific fatigue with diminished capacity for 
physical exertion. After an initial evaluation, and discussions of 
the nature of the diagnosis (with reprints from the literature) and 
the importance of physical fitness, I made two follow-up 
appointments. I judged the sarcoidosis to be stable and improv- 
ing, and I discussed follow-up as symptoms dictated with the 
patient. 

Three years later he came back. He had lost weight, and had 
symptoms of gastrointestinal distress and abnormal liver func- 
tion tests. The chest radiograph was unchanged but pulmonary 
function was reduced (judged to be secondary to abdominal 
bloating and lack of fimess). 

After six weeks he had not improved, and so was hospital- 
ized for three days. A consultant gastroenterologist did not 
clarify the diagnosis. I prescribed symptomatic treatment for 
the gastrointestinal distress and saw him two months later (his 
weight was stable and he was improving); a third follow-up was 
scheduled. He did not keep that appointment, so 1 assumed that 
his improvement continued since I had made explicit the option 
to return if needed. Over the subsequent years I received 
communications from both the patient (he was doing "belter") 
and his brother, a former medical student, now MD ("my 
brother is doing okay"). There were no formal appointments 
because the patient lived some distance away. 

Dr. Bryan is Professor, Division of General Medicine and Clinical 
Epidemiology, Department of Medicine, UNC School of Medi- 
cine, CB# 71 1 0, 5039 Old Clinic BIdg.. Chapel Hill 27599. 



The patient, although having graduated from Notre Dame 
and earning a second degree at North Carolina State University, 
had not led a vigorous life since high school. He had always 
been limited in energy, exertional capabilities, and work initia- 
tive. This troubled his physician brother who, when we met at 
a medical meeting, discussed the situation with me and reiter- 
ated it in one of his letters. I responded, noting my own 
frustration about the lack of an explanation for his brother's 
"neurasthenia." I referred him to Norman Cousin's book, 
Anatomy of an Illness. 

In 1989, the patient's brother asked me to see the patient 
again because he had become "worse." His central complaint 
was an inability to breathe properly. Lung function tests showed 
a marked decrease in vital capacity, but a normal diffusion of 
carbon monoxide and normal blood oxygenation. The chest x- 
ray was unchanged, but the physical exam showed skin lesions 
consistent with sarcoidosis and some node enlargement. Be- 
cause of the confusing lung function values and the fact that the 
breathing complaint was now paramount, I arranged for the 
patient to be cared for by a colleague in pulmonary medicine. 
This physician could not explain the test results, but "bit the 
bullet" and gave prednisone with improvement in subjective 
symptoms. 



A Sudden Bombshell 

One day before the three years since my last formal encounter 
with the patient had elapsed, I was notified of a malpractice suit 
(SI million). Accompanying the notification was a long, angry 
diatribe by the former medical student (now emergency physi- 
cian) brother alleging that by not using prednisone in the years 
before referring the patient I was guilty of negligence. I was 
responsible for the patient's lackof fulfillment in life. I promptly 
(before being told by my lawyers not to communicate directly) 
wrote a letter asking the ex-student to clarify the grounds for his 
anger, and inviting him to come talk to me (he did not). Then 
began years of legal proceedings. 



246 



NCMJ July/August 1996, Volume 57 Number 4 



During the next several years, 1 was intermittently re- 
minded of the brother's anger in the allegations set forth in the 
suit. It later came out (although he later denied it under oath) that 
a physician in another community (who had arranged pulmo- 
nary function studies for the patient) told the physician brother 
that 1 should be hung by my [anatomy] for not giving corticos- 
teroids back in the 1970s. 

The only recourse for answering this anger was to deliver 
myself (passively) into the hands of my "handlers" (the lawyers 
who represented the malpractice insurer for my clinical prac- 
tice). They arranged the depositions, assigned a defense lawyer, 
dealt with the legal maneuverings, and generated the formal 
papers (which by the lime the process ended formed a stack 
approximately 24 inches high). 



Strategy and Tactics 

The plaintiffs lawyer apparently had a hard time finding an 
expert witness to support his position and asked for a year's 
delay in the proceedings. Then the case was reactivated and the 
jousting commenced. My lawyer and his attended depositions 
by me, my two experts, and the colleague who was currently 
caring for the plaintiff. Papers and reports were collected from 
all sources, including the many "consultants" seen by the 
plaintiff in various parts of the country. All gave negative 
opinions about the value of steroids in treating the patient's 
complaints. (I never learned whether these opinions and testi- 
monies were formally examined by a judge.) During the year 
before trial we spent a mandated half day in a "dispute setde- 
ment/arbitration" setting. The plaintiff again demanded money, 
and we again refused. 

Then the trial was on! A date was set three months ahead. 
My schedule had already been cleared (patient appointments 
changed) when I received notice that the plaintiff's lawyer had 
a "conflict." A new date was set for one month later (in the 
middle of our family vacation), and then for three months later. 
As this date approached and the judge was assigned, my lawyer 
requested a change because the assigned judge had himself used 
the plaintiff's lawyer in a past malpractice suit on behalf of the 
judge's wife. I had no problem with the judge — I was taking 
care of his father and had cared for his mother (there had been 
some conflict between the judge and his father over some of the 
care decisions). 

The judge finally decided not to excuse himself one week 
before the session of court commenced. I scrambled to find 
teaching substitutes, rescheduled my clinics (involving much 
angst on the part of patients who had long-scheduled appoint- 
ments and lived at some distance — two from out of state). 

When the trial commenced, the judge announced that he 
had long-standing plans for the Friday of trial week, hence court 
would not meet that day (my secretary was able to reconvene a 
canceled clinic). Selecting a jury took the first day (there were 
not enough jurors in the pool — some were excused because 
they knew me, or because I had cared for a family member, or 



because of prior bad experiences or feelings about civil pro- 
ceedings of this sort). 



In the Fray 

The plaintiff's lawyer presented his case for the alleged mal- 
practice; my lawyer responded; and "testimony" was given by 
the plaintiff, the plaintiff's brother, and their "expert." The 
"expert" physician (distinguished and well-crcdentialed) ap- 
peared via a videotaped deposition. A technician and the two 
lawyers had traveled to New Haven to talk to a pulmonology 
professor, who had never seen the patient. His sworn testimony 
reflected his "control philosophy" for sarcoid cases. He made 
extensive laboratory tests, mandated follow-up (he sent docu- 
mented letters if appointments were not kept), but offered no 
specific guidelines. My lawyer brought out the fact that this 
doctor appeared often as an "expert" witness — for $350 per 
hour! He had previously served as a witness for this particular 
plaintiff's lawyer. 

At the trial, my experts appeared at their scheduled times. 
The first was allowed to testify before I had completed my 
testimony, because he had traveled across the state. After 
testifying in support of my case, he was questioned by the 
plaintiff's lawyer in detail over every chart entry, laboratory 
study, discussion, and communication. My wimess gave his 
opinion that the standard of care had been met and that the 
decisions made in the 1970s had been proper, but he was 
denigrated because he was a young physician who had not 
finished his training in medicine in the 1970s. 

The questioning was so drawn out that it was clear that we 
would not to be finished by the end of court day (or week); my 
expert would either have to return when the court reconvened 
on Monday or the jury would be told that his testimony was 
invalid (my lawyer perceived this to be the strategy). He did 
return for a brief time on Monday — a real sacrifice and really 
appreciated by me. My second expert, another pulmonologist 
who worked at a nearby university then appeared, reaffirmed 
that the standard of care had been met, and pointed out the lack 
of indication for corticosteroid use. He refuted opposing opin- 
ions (drawn from the literature and textbooks used in a selective 
and often out-of-context fashion). His denied that the pulmo- 
nary function studies indicated "lung involvement and manda- 
tory steroid use." His veracity was questioned because he knew 
of me and had seen patients for me on referral. 

Then my colleague (the patient's current physician) was 
called (he had canceled his clinic) and he reiterated his involve- 
ment, his interpretation of the various citations from the litera- 
ture, and his own initial ambivalence about using steroids in the 
case. 

The verbal and nonverbal techniques of the lawyers on 
both sides were interesting to watch and analyze. The plaintiff's 
lawyer was particularly adept at calling minor lab variations 
"critical points in decision-making." He was aggressive, con- 
frontational, and blame-casting. As my interrogation contin- 



NCMJ July/ August 1996, Volume 57 Number 4 247 



ued, he implied a lack of caring, a lack of competence, an 
avoidance of responsibility (1 did not make the return visits 
explicit) and wrongdoing in not using prednisone in stage 1 
sarcoidosis (with no symptoms attributable to that disease). 

These tactics continued unchanged as both sides made 
summations. The plaintiffs lawyer had the "last word" and 
reiterated everything that he had said before, with colorful 
interpretations and judgments about my character and capabil- 
ity (I was especially interested in his citation of my alleged 
failure to follow up a marginally elevated lab test, after which 
he stated "I wouldn't want [Bryan] to care for anyone I loved." 
After the trial I asked him about his relationship to his sister and 
brother-in-law, who are my patients. He said, "Aw, this is just 
what we do.") 



Lessons in Survival 

Of course the allegations hurt, just as the trial hurt, and being 
confronted, and having my integrity impugned. I regretted the 
waste of time in preparation, in the trial, in the canceled clinics, 
in wondering about what had gone awry; I regretted the obvious 
anger and hate (hopefully not just avarice) expressed through- 
out the entire affair by the plaintiff's family. 

After a sleepless night (one of many), we went back to 
court. Thejudge instructed thejury,thejury met fora brief time. 



When the "not guilty" decision was announced, the world 
brightened. I shook hands with the physician brother, but the 
sister informed me that "1 would answer to God" for what had 
happened. Anger and hurt clearly continue on her part 
This experience has caused me to reflect that: 

1) No physician should ever assume that patients (no matter 
what their educational level) will accept responsibility for 
educating themselves or interacting in an open manner. 
Passing the "hot potato" of responsible follow-up, and 
monitoring should be well-documented. Is control of the 
patient a better philosophy than patient autonomy? 

2) In malpractice litigation, the common rules of civility, 
openness, and honesty are put on hold. This is war, and the 
participants are adversaries. 

3) The costs of the process are massive. My insurance com- 
pany said that "my side" spent $70,000 in "defense." This 
figure, I am sure, was matched by the plaintiff. But these 
dollars do not take into account the time (and sleep) lost, the 
cost to society of a 10-day jury trial, the costs of arbitration, 
or the "overhead" costs of keeping the civil and legal 
"machinery" in place to deal with these issues. 

All this has been very educational. I am grateful to be 
scarred but alive. I still have moments of "flashback" (post- 
traumatic shock) and other phenomena. Maybe we survivors of 
malpractice litigation should form a VMW (Veteran of the 
Malpractice Wars) support group. G 



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248 



NCMJ July/August 1996, Volume 57 Number 4 



PERSPECTIVES OF MEDICINE 



Liver Transplantation 

Patient Selection and Organ Allocation 



James F. Trotter, MD, J. Gregory Fitz, MD, and Pierre A. Clavien, MD, PhD 



Liver transplantation is a rapidly evolving technique that has 
emerged as the most effective and cost-efficient way to treat 
selected patients with liver failure.'"^ The number of patients 
undergoing liver transplantation has grown at a remarkable 
rate, doubling over the past five years (from 1,700 transplants 
in 1988 to 3,400 in 1993). The number of patients waiting for 
hepatic replacement has likewise grown, from 600 to over 
3,000 during the same period. These numbers directly reflect 
the success of the procedure (one-year survival rates after liver 
transplantation have improved from around 20% 20 years ago, 
to the current one-year survival rate of 85% or more). 

As the number of acceptable candidates for transplantation 
increases and indications for the procedure broaden, the respon- 
sibilities of patient care will shift. Physicians outside of trans- 
plant centers will play a larger role in patient management, 
before and after surgery. It is important that all physicians 
understand the broad outlines of the liver transplantation pro- 
cess. In this article we give an overview of specific issues in 
patient selection for liver transplantation. These are important 
issues of practical value to any physician whose patients have 
advanced liver disease. 



Patient Selection 

A multidisciplinary team evaluates patients for liver transplan- 
tation on a case-by-case basis. Selection involves both the art 
and scienceof medicine, but the fundamental question that must 
be addressed is whether a candidate will be better off in five 
years with or without a transplant. Each answer is highly 
individualized, depending on the severity and natural history of 
the underlying liver disease and the availability of alternative 
medical and surgical options." Overall, the indications for and 
contraindications to, and the timing of transplantation are the 
most important issues. 

The authors are with the Liver Transplantation Program at Duke 
University Medical Center. Drs. Trotter and Fitz are with the 
Department of Medicine; Dr. Clavien is with the Department of 
Surgery, Box 3247, DUMC, Durham 27710. 



In general, patients with liver failure from a number of 
different diseases (Table 1, below), who have life-threatening 
or life-limiting complications, and who have no other effective 
life-prolonging treaunent options, are candidates for liver trans- 
plantation (Table 2, below). For example, patients with bleed- 
ing esophageal varices and advanced liver disease (Child's 
class B or C liver failure; see Table 3, next page) have such a 
poor prognosis that they are clearly candidates for transplanta- 
tion. Quality-of-life issues 
also determine a patient's 
potential candidacy for 
liver transplantation — 
profound fatigue or itch- 
ing caused by liver dis- 
ease makes the patient a 
candidate for transplanta- 
tion. 

Table 4, next page, 
lists the common absolute 
and relative criteria we use 



Table 1. Common causes 
of liver failure leading to 
transplantation 

Primary biliary cirrhosis 
Primary sclerosing cirrhosis 
Cryptogenic cirrhosis 
Hepatitis B 
Hepatitis C 
Autoimmune hepatitis 
Alcoholic cirrhosis 



Table 2. Indications for liver transplantation 

Severe chronic liver disease with: 

Spontaneous bacterial peritonitis 

Ascites 

Encephalopathy 

Variceal bleeding with impaired liver function 

(Childs B or C, see Table 3, next page) 
Increased prothrombin time not corrected by 

vitamin K 
Serum bilirubin > 5 mg/dL 
Serum albumin < 2.5 g/dL 
Recurrent cholangitis 
Hepatorenal syndrome 

Life-limiting complications: 

Severe fatigue 

Severe, refractory pruritus 



NCM J July/ August 1996, Volume 57 Number 4 249 



to exclude patients from transplan- 
tation. Originally, patients over age 
60 were not considered for liver 
transplantation because they were 
thought to have a high probability of 
coexisting medical problems and 
limited physiologic reserve. The 
surgical risks were felt to be pro- 
hibitive and the chances of obtain- 
ing long-term overall improvement 
in health, minimal. However, as the transplantation process has 
been refined, many patients older than 60 have had successful 
surgery. Now most centers will transplant patients over age 60, 
or even 65, if they have been carefully evaluated to exclude the 
presence of comorbid conditions. In 1993, 5% of all liver 
transplants performed in the US were in patients over the age of 
65, and the number is Ukely to increase. At Duke, 20% of the 
patients presently awaiting liver transplantation are over 60 
years old. 

The medical condition of the patient at the time of trans- 
plantation is the single most important factor predicting sur- 
vival and long-term good outcome. Patients unstable enough to 
be in an intensive care unit at the time of transplant have a 
postoperative mortality approaching 40%, four-fold higher 
than the 10% expected in stable outpatients. In critically ill 
patients, the financial costs are three-fold greater than in stable 
outpatients. These survival and cost issues argue strongly that 
transplantation, if it is to be considered at all, should be carried 
out before patients become critically ill. 

Appropriate timing is also complicated by another impor- 
tant factor, time spent on the waiting list. The median time 
waiting for liver transplantation has increased 40% each year 
since 1990 (to 171 days in 1994). Even after a patient has been 
evaluated by a transplant center and placed on the list, a waiting 
time of six to 12 months is common — a time during which the 
medical condition of patients with advanced liver disease can 
deteriorate. In fact, deterioration while waiting for transplanta- 
tion is one of the most significant problems in the pretransplant 
management of patients with advanced liver disease. All too 
commonly patients in "good" medical condition on the day that 
they are listed for transplant develop significant complications 
such as variceal bleeding. They may become critically ill or 
even die awaiting transplantation. 

Progression of liver failure can be predicted from the 
natural history of liver diseases. About 50% of patients with 
cirrhosis who develop variceal bleeding die within one year, 
and 50% of those with cirrhosis and ascites die within two years. 
It is not surprising that the number of patients who have died 
while awaiting liver transplantation has increased almost three- 
fold between 1988 and 1993. To have the best chance for a 
successful transplantation, patients must be referred to a trans- 
plant center long before they develop significant complica- 
tions — either from underlying liver disease or from concomi- 
tant, nonhepatic diseases (obesity, diabetes, heart and lung 
disease, or pre-existing psychiatric conditions) that signifi- 



Table 3. Classification 


of Child's class liver failure 




Child's class 


A 


B 


C 


Serum bilirubin (mg/dL) 


<2.0 


2.0-3.0 


>3.0 


Serum albumin (g/dL) 


>3.5 


3.0-3.5 


<3.0 


Ascites 


none 


easily controlled 


poorly controlled 


Neurologic 


none 


minimal 


coma 


Nutrition 


excellent 


good 


poor 



Table 4. Contraindications to liver transplantation 

Absolute: 

HIV positive 

Current extrahepatic malignancy 
Large (> 5 cm) or multiple (> 3) hepatomas 
Severe cardiopulmonary disease 
History of significant medical noncompliance 
Active substance abuse 
Anatomic anomalies precluding transplantation, 
such as diffuse mesenteric vein thrombosis 

Relative: 

Age > 65 years 

Current infection 

Coexisting medical problems 

Hepatitis B e antigen positive or HBV DNA positive 

Portal vein thrombosis 



cantly increase the risk of liver transplantation. Transplant 
candidates must be evaluated very carefully for any indications 
of these conditions. 

The perioperative risk associated with comorbid condi- 
tions must be assessed by experienced specialists who fully 
understand the interactiveeffects of the comorbid condition and 
the underlying liver disease, postoperative immunosuppres- 
sion, and intraoperative physiologic changes specific to Hver 
transplantation. Communication between the transplant sur- 
geon, transplant hepatologist, and consulting specialist is criti- 
cal. 

A successful long-tenm outcome to liver transplantation 
requires adequate social support The two most important 
characteristics of the successful transplant recipient, not sur- 
prisingly, are their ability to comply with the medicine regimen 
and to respond rapidly and appropriately to recommendations 
of the transplant team. Failure to take immunosuppressive 
medications at any time after transplantation can rapidly lead to 
rejection of the liver and irreversible graft failure. And trans- 
plant patients must make continuous, albeit usually minor, 
adjustments in their medication. During the first month, this 
requires weekly or biweekly blood tests and weekly communi- 
cation with the transplant center. 

The severity of postoperative complications can be seri- 
ously compounded by delay in diagnosis. To compound mat- 



250 



NCMJ July I August 1996, Volume 57 Number 4 



ters, the typical signs of infection are masked by the immuno- 
suppressive state, and clinical signs of infection may be difficult 
to differentiate from other problems such as rejection. Any 
deviation from the ideal postoperative course requires immedi- 
ate and careful evaluation including chest x-ray, blood tests, 
abdominal imaging, and sometimes liver biopsy. This means 
that patients must be able to identify problems, to report them 
immediately to their physician, and to return immediately to the 
transplant center for urgent care when needed. Because of the 
need for active interchange with the transplant center, patients 
must have reliable phone communication, u^ansportation, fam- 
ily and social support, and adequate insight into their medical 
situation. Patients who are unwilling or unable to follow the 
rigorous medical course uniformly have poor long-term results 
after transplantation. 



"...carefully selected alcoholic 

patients with cirrhosis are excellent 

stewards of their donor organs and do 

quite well after liver transplantation." 



Alcoholic Cirrhosis in 
Liver Transplantation 

Caring for patients with substance abuse is difficult. Even in the 
face of life-threatening complications related to their substance 
abuse, many continue their self-destructive behavior. It has 
been suggested that treating such patients is futile, and that life- 
prolonging surgical therapies represent a waste of medical 
resources. But is has now been clearly shown that a subgroup of 
patients with alcoholic cirrhosis have an excellent outcome.^ 

Many people drink alcohol excessively, but only 10% 
develop cirrhosis. Of the 10%, the vast majority are unfit for 
liver transplantation, either because of associated alcohol- 
related disease, or the concomitant behaviors associated with 
excessive drinking. Alcoholism affects persons of all social 
strata, but the typical patient with alcoholic cirrhosis evaluated 
in the Duke Liver Transplant Clinic is an unmarried, 45-year- 
old man who has been drinking for 20 or more years. He often 
has lost his job, alienated his family, lost social support systems, 
and has far-advanced liver disease when first seen. Such pa- 
tients are poor candidates and transplanting them is not in the 
best interest of the patient, society, or the transplant center. 
However, carefully selected alcoholic patients with cirrhosis 
are excellent stewards of their donor organs and do quite well 
after Uver transplantauon. 

The likelihood that a patient will remain abstinent depends 
on the pretransplant evaluation of the pafient's alcphol abuse. 
For the past 12 years we have used stringent selecfion criteria 
in our program and have had excellent results. We require that 
all patients with a history of alcohol abuse remain sober for at 
least six months before listing them for transplantation, and 



remain sober during the time they are awaiting transplant. This 
means an additional four to 12 months of sobriety. Each patient 
is evaluated by our psychiatrist and alcohol abuse counselor, 
both of whom have extensive experience with this difficult 
group of pauenls. Approximately 50 of our 300 liver transplants 
have been performed for alcoholic liver disease; only two 
patients have resumed alcohol abuse following transplantation. 



Organ Allocation in North Carolina 

The process of listing patients for transplant and the allocation 
of organs to potential recipients have recently attracted a great 
deal of attention. Organ allocation has been publicly scrutinized 
in the past year primarily because of the speed with which 
certain celebrity patients have received donor organs. The 
United Network of Organ Sharing (UNOS), based in Rich- 
mond, Virginia, directs the allocation of all donor organs for 
transplantation in the US. In North Carolina, allocation is 
administered by three organ procurement organizations (OPOs): 
Carolina Organ Procurement Agency, Lifeshare of the Caroli- 
nas, and Lifecare of the Carolinas, according to UNOS guide- 
lines. OPOs serve as administrative and logistical clearing- 
houses for harvesting and allocating donor organs to appropri- 
ate patients. Liver transplant centers are required to be members 
of UNOS and follow UNOS guidelines for organ allocation for 
every transplantation performed at their center. All potential 
recipients of transplanted livers must be listed on the UNOS 
computer. Allocation is made using a point system based on 
medical urgency, time waiting, and ABO blood type. Medical 
urgency is classified as follows: 

Status I: In ICU, not expected to live more than one week. 
Patient may be listed status I for only 14 days during their life. 
Status II: In hospital for at least five days. 
Status III: At home with progressive liver disease. 
Status IV: At home with stable liver disease. 
S tatus I patients have the highest priority for an available organ, 
followed in order by status 11, III, and IV. Patients are also given 
priority based on how long they have been waiting for an 
available organ. Those waiting the longest have the highest 
priority. Finally, organs are allocated based on the ABO blood 
type. With few exceptions, donor organs are given to recipients 
of identical blood type. 



"Allocation is made using a point 
system based on medical urgency, 
time waiting, and ABO blood type." 



In North Carolina, once a donor liver becomes available, 
the OPO uses the UNOS listing to determine which patient is 
eligible for the organ. The recipient's transplant surgeon is 
notified and offered the liver. After assessing the clinical situ- 



NCMJ July/August 1996, Volume 57 Number 4 251 



ation of donor and recipient, the transplant center may accept 
the organ or "pass," in which case the organ is offered to the next 
NC patient on the UNOS list. An organ may not be accepted for 
a potential recipient because of size discrepancy (donor organ 
from a 120-kg man for a 50-kg recipient), a clinical history 
suggesting that the donor liver may be significantly damaged 
(say, from heavy alcohol use), or donor serology positive for 
hepatitis B or HIV. If there is a clinical suspicion of liver 
steatosis, a liver biopsy is taken at the time of organ recovery. 
Livers containing more the 50% fat are usually not used. 



Summary 

Liver transplantation represents a major advancement in treat- 
ing selected patients with advanced liver disease. The keys to 
successful outcome include: 1) early evaluation and listing for 
transplantation before the patient develops severe complica- 
tions of cirrhosis; 2) control of comorbid conditions; and 3) a 
cooperative and dynamic interchange between the transplant 
center and otherphysicians involved in thecareof the patient □ 



References 

1 Munoz S J, Friedman LS. Liver transplantation. Med Clin North Am 
1989;73:1011-39. 

2 Slarzl TE, Demetris AJ, Van Thiel D. Liver transplantation. N Engl 
J Med 1989;321:1014-22. 

3 Wright TL. Liver transplantation for chronic hepatitis C viral 
infection. Gastro Clin North Am 1993;22:231-42. 



4 Kirk AD, Clavien PA. Liver transplantation. In: Sabiston DC, ed. 
Textbook of Surgery: The Biological Basis of Modem Surgical 
Practice. In press, 1996. 

5 Lucey MR. Liver transplantation for the alcoholic patient. Gastro 
Clin North Am 1993;22:243-51. 




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252 



NCMJ July/August 1996, Volume 57 Number 4 



PERSPECTIVES OF MEDICINE 

Radial Keratotomy 

What Is It? Where Did It Come From? 

What Has Happened With It in the United States? 

Bill Satterwhite, III, JD, MS IV 



For centuries people have struggled to remedy nearsightedness 
by attempting to change the shape of the cornea. The ancient 
Chinese reportedly slept with sandbags on their eyes to flatten 
their corneas in an attempt to correct nearsightedness (myo- 
pia).' In the mid-lSOOs Dr. J. Ball advertised that he could cure 
myopia with an invention consisting of an eye cup and a spring- 
mounted mallet that struck the cornea through the closed eyelid 
to flatten the cornea. "It restores your eyesight and renders 
spectacles useless," Ball claimed.' 



What Is Radial Keratotomy? 

We have made a lot of progress in correcting nearsightedness 
since the days of Dr. Ball. Spectacles of various shapes and 
styles, and contact lenses of different colors and gas permeabil- 
ity have been and remain the mainstays for correcting myopia. 
Recently, however, there has been great popular interest in 
radial keratotomy, a surgical procedure in which a series of 
radial incisions (arranged like the spokes of a wheel) are made 
in the cornea, altering its shape and its refractive power so that 
myopia is reduced.^ 



fovea. This causes distant images to be seen as blurred (Fig. 
2).^'' As an object is brought closer to an uncorrected myopic 
eye, it reaches a point at which the object comes into focus on 
the fovea. This is called the "far point" of the eye (Fig. 3, page 
255)." In people with myopia, the far point is closer to the eyes 
than in people with normal vision, hence the term "near- 
sighted." Glasses and contact lenses correct myopia by altering 
the refraction of incoming light rays so that they focus the image 
at the fovea. This creates a virtual image at the far point (Fig. 4)." 
Radial keratotomy, on the other hand, corrects myopic 
eyes by actually altering the refractive power of the cornea 
itself. A series of radial incisions in the paracentral and periph- 
eral cornea weaken the cornea and allow intraocular pressure 
(circumferential stress ["CS"] and perpendicular su^ess ["PS"] 
in Fig. 5 , page 256) to bow the incised area forward." The central 
cornea is thereby flattened, decreasing its refractive power. As 
the incisions heal, they fdl with collagen and epithelium, 
thereby increasing the surface area of the cornea and causing 
permanent cental corneal flattening and peripheral corneal 
steepening (Fig. 6).^'' The flattened cornea refracts light rays 
differently than when it was more curved. In the ideal case, light 
rays now focus onto the retina (Fig. 7).* 



How Does Radial Keratotomy Work? 

In the normal, or emmetropic eye, incoming light rays are bent 
by the cornea and lens of the eye to focus on a point on the retina, 
called the fovea (Fig. l,nextpage).''"Intheuncorrectedmyopic 
eye, incoming light rays are focused on a point anterior to the 



Mr. Satterwhite is a fourth-year student at Bowman Gray School 
of Medicine, Medical Center Boulevard, Winston-Salem 271 57. 



Where and How Did 
Radial Keratotomy Begin? 

The first serious efforts at surgically correcting myopia were 
made by Dr. Tsutomu Sato in Japan in the 1950s. In contrast to 
current procedure, Dr. Sato made radial incisions in both the 
anterior and posterior sides of the cornea.' He reported an 
average reduction in myopia of 3.0 diopters (a "diopter" is a 
measure of the refractive power of lenses, commonly abbrevi- 
ated by a capital "D"). Despite its success Dr. Sato's procedure 
met with indifference because of the development of contact 
lenses during the late 1 950s. In a way this was fortunate because 



NCMJ July/August 1996, Volume 57 Number 4 



253 



3-4 mm 

diameter 

pupil 



in 1965, five years after Sato's death, the first 
case of bullous keratopathy (a form of corneal 
edema) developed in one of Sato's patients 12 
years after surgery." Ultimately, 86% of the 
eyes on which Sato operated developed bullous 
keratopathy (at an average of 20 years after 
surgery).' We now know that incisions in the 
posterior cornea permanently damage the en- 
dothelial cells — cells whose function is the pres- 
ervation of corneal clarity and fluid transport." 
Aware that corneal edema resulted from 
Sato's posterior incisions, surgeons in the So- 
viet Union began, in the late 1960s and early 
1970s, to attempt correction of myopia through 
incisions in the anterior cornea alone. In 1974, 
after successful studies in rabbits. Dr. S. N. 
Fyodorov began performing freehand anterior 
radial keratotomy in humans using a razor blade 
fragment in a blade holder. He checked the 
depth of the incisions with a depth gauge or 
"dipstick."" Fyodorov subsequently developed 
a guarded micro-metric knife to precisely regu- 
late the depth of the incisions.* He also invented 
a circular clear-zone marker and radial markers 
("pizza-cutters"), which when impressed on the 
cornea prior to surgery, left marks on the cor- 
neal surface to guide the surgeon's knife." In his 
1982 results reporting surgery on 230 eyes, 
Fyodorov found that 100% of the eyes had a 
final refraction within 0.5D of perfect vision 1 .5 
years after surgery.' 



What Has Happened 
With Radial Keratotomy 
in the US? 



Unlike the orderly development seen in Japan 
and Russia, radial keratotomy in the US grew 
because of a chaotic mix of social, economic, 
political, and scientific forces. Radial keratotomy 
was introduced in this country largely through 
reports in the media that created intense public 
interest. Then a few entrepreneurial ophthal- 
mologists promoted its use through advertising 
and direct public sales. On the political front, 
organizations devoted to refractive keratotomy 
sprang up and battled one another, even in the courts. And 
finally, individuals and groups undertook laboratory investiga- 
tion and clinical modification of surgical techniques." 

Though several individuals and societies have studied the 
results of radial keratotomy, the Prospective Evaluation of 
Radial Keratotomy (PERK) Study is considered the "official" 
study of radial keratotomy in the US. Twelve clinical centers 
collaborated on the PERK study, which was funded in early 



Emmetropic Eye 




Fovea 



Figure 1 



Reprinted witti permission from Mosby-Year Boolt, Inc. 



Uncorrected Myopic Eye (-1 .00 D) 



3-4 mm 

diameter 

pupil 




Fovea 



>- Figure 2 

Reprinted wifti permission from Mosby-Year Boole, Inc. 

1 98 1 by the National Eye Institute.' Ten-year follow-up results 
were reported in October 1994, and the positive results were 
remarkable. Fifty-three percent of eyes had 20/20 vision or 
better; 85% had 20/40 vision or better, and only 2% had 20/200 
vision or worse.' Seventy percent of the patients needed no 
contact lenses or glasses for distance vision. The investigators 
concluded that radial keratotomy "can effectively reduce but 
not completely eliminate myopia," that the procedure "had a 



254 



NCMJ July/ August 1996, Volume 57 Number 4 



Far point 
conjugate 
with fovea 



reasonable margin of safety," and that "vision- 
threatening complications were rare."' 

The PERK study did report one major 
finding of concern. There was a long-term 
instability of refractive error, so that 43% of 
the eyes became more hyperopic (farsighted) 
by l.OOD or more six months to 10 years after 
surgery.' At five years, the PERK study had 
found only 22% of patients with a progressive 
shift toward hyperopia.'" The hyperopic shift 
was unrelated to age, sex, corneal thickness, 
average central keratometric power, intraocu- 
lar pressure, or refractive error at six months 
after surgery ' Statistically significant factors 
predicting hyperopic shift were the length of 
the radial incisions, the diameter of the central 
clear zone, and the diameter of the cornea, but 
these accounted for only 5% percent of the 
variation in refractive change. The cause, maxi- 
mal amount, and duration of the hyperopic 
shift are unknown.' According to the PERK 
investigators, the shift results from the same 
mechanism that produces the initial central 
corneal flattening after surgery — an increase 
in the width of the corneal incisions.' The 
practical effect of the hyperopic shift is that 
some patients will need 
glasses to correct near vision 
because they become far- 
sighted. Aware of the possi- 
bility of gradual hyperopic 
shift, most ophthalmological 
surgeons typically "undercor- 
rect" myopiaby making fewer 
radial incisions, shortening 
their length, and making inci- 
sions less deep in the cornea. 

Other than the hyperopic 
shift, the only severe compli- 
cation of radial keratotomy is 
corneal perforation at the time 
of surgery, and this is rare.^ 
Neither endothelial damage to 
the posterior side of the cor- 
nea nor corneal edema has 
been reported with current 
techniques." Many patients 

report mild postoperative pain, and visual acuity that fluctuates 
from morning to evening for several weeks.^ More serious but 
less common complaints include overcorrection or under- 
correction of the refractive error, a nondisabling glare ("star- 
bursts"), and problems fitting contact lenses." TTiere is no 
definitive information about whether the corneal scars are 
more — or less — likely to rupture after severe occular trauma.' "•' 



Uncorrected Myopic Eye 




Foveo 



Figure 3 



Reprinted wifh permission from Mosby-Yeor Book, Inc. 



Spectacle-Corrected Myopic Eye 




Correcting 
minus lens 



Figure 4 

Reprinted witfi permission from Mosby-Yeor Book, Inc. 

Conclusion 

Radial keratotomy has become a popular procedure. Approxi- 
mately 250,000 operations are performed in the US each year.' 
In this country, it has been primarily a demand-driven rather 
than disease-driven treatment." The average cost for anterior 
radial keratotomy generally ranges from $800 to $ 1 ,000 per eye 

Continued on page 257 



NCMJ July/August 1996. Volume 57 Number 4 255 



Radial Kerototomy 



Before 
Surgery 





Figure 5 

Reprinted with permission From Mosby-Yeor Book, Inc. 
Before Surgery Radial Kerototomy 





Figure 6 

Reprinted with pormisjion from A*tejby-Yeaf Book, Inc. 




Radial 
Keratotomy 



Figure 7 

Reprinted with permission from Mosby-Yeor Book, Inc. 

256 NCMJ July/ August 1996, Volume 57 Number 4 




and is usually not covered by insurance."' Patients do 
appear to be satisfied. Two studies of patient satisfac- 
tion found that 7 1 % and 48% were "very satisfied," and 
only 10% and 13% were dissatisfied.' 

Radial keratotomy has come a long way from 
Japan, to Russia, and finally to the US. The procedure 
has been refined, primarily by individual ophthalmolo- 
gists who were not working under the auspices of an 
organized protocol or study. It appears to be a reason- 
ably safe and effective procedure, but its outcome is not 
perfectly predictable. Will it stand the test of time? Will 
it be replaced by photorefractive keratectomy, a new 
laser surgical procedure for correcting nearsighted- 
ness? No one can say for sure, but radial keratotomy is 
definitely now a part of modem ophthalmology. Q 

Acknowledgment: The author thanks CharlotteWhitted 
for her technical assistance in rendering the figures. 



References 

1 Waring GO. History of radial keratotomy. In: Sanders 
DR, Hofmarm RF, and Salz J, eds. Refractive Corneal 
Surgery. Thorofare, NJ: Slack, 1986, pp 3-14. 

2 Binder PS, Waring GO, Arrowsmith PN, Wang C. Histo- 
pathology of traumatic rupture of the cornea after radial 
keratotomy. Arch Ophthalmol 1988;106:1584-90. 

3 Waring GO, Lynn M J, McDonnell PJ, et al. Results of the 
Prospective Evaluation of Radial Keratotomy (PERK) 
study 10 years after surgery. Arch Ophthalmol 1994;112: 
1298-307. 

4 Waring GO. Refractive keratotomy for myopia and astig- 
matism. St. Louis: Mosby-Year Book, 1992. 

5 Rowsey JJ. Radial keratotomy: principles and practice. 
In: Spaeth GL, ed. Ophthalmic Surgery: Principles & 
Practices. Philadelphia: Saunders, 1990, pp 197-211. 

6 Sato T, Akiyama K, Shibuta H. A new surgical approach 
to myopia. Am J Ophthahnol 1953;36:823-9. 

7 Kanai A, Tanaka M, Ishii R, Nakajima A. Bullous 
keratopathy after anterior-posterior radial deratotomy for 
myopia and myopic astigmatism. Am J Ophthalmol 1 982; 
93:600-6. 

8 Fyodorov SN, Agranovsky AA. Long-term results of 
anterior radial keratotomy. J Ocular Therapy Surg 1982; 1: 
217-23. 

9 Waring GO, MoffiU SD, Gelender H, et al. Rationale for 
design of the National Eye Institute Prospective Evalua- 
tion of Radial Keratotomy (PERK) study. Ophthalmol- 
ogy 1983;90:40-58. 

10 Waring GO, Lynn MJ, Nizam A, et al. Results of the 
evaluation of radial keratotomy (PERK) study five years 
after surgery. Ophthabnology 1991 ;98:1 164-76. 

1 1 Waring GO. Radial keratotomy. In: Kaufman HE, Barron 
B A, McDonald MB, Waltman SR, eds. The Cornea. New 
York: Churchill Livingstone, 1988, pp 849-96. • 

12 American Academy of Ophthalmology. Radialkeratotomy 
for myopia. Ophthalmology 1993;100:1 103-15. 

13 Sugar A. Has radial keratotomy fmally come of age? 
Ophthalmology 1993;100:979-80. 




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your past credit! Provide your name, degree, phone number, 
amount you want to borrow, and best time to call. Norman 
Roark, Broker, P.O. Box 1958, Banner Elk, NC 28604, 704/ 
898-8655 (phone and fax). 

ATTENTION HUNTERS: Cypress Bay Plantation, Hamp- 
ton County, SC, is looking for a limited number (8-10) of 
quality deer hunters for 1996 season (Aug 15-Jan 1). Family 
participation encouraged. Camper hook-ups and cabin avail- 
able. Call Dr. Skeet Burris, 803/524-4468. 

BUSY GASTROENTEROLOGIST PRACTICE: Seeking 
energetic board-eligible/board-certified gastroenterologist. 
Strong preference to someone with biliary experience. Prac- 
tice located in the southeastern region of the state near 
beaches. Please submit C Vs to P.